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THE HEAET AND ITS DISEASES-

WITH THEIR TREATMENT.

BY

J. .mum FOTHERGILL, M.D., M.R.C.P.

H. K. LEWIS, 13C, GOWER STREET,

1872.

n>

TO

GEORGE ROLLESTON, M.D., F.R.S.,

LIMAORE PE0FES30K OP ANATOMY AND PHYSIOLOGY IN THE UNIVERSITY OF OXFOKD,

IN

GRATEFUL REMEMBRANCE OF REPEATED ACTS OF KINDNESS AND

ENCOURAGEMENT,

THIS WORK IS DEDICATED,

BY

THE AUTHOR.

PREFACE.

While our literature on Heart Disease contains the syste-
matic works ot Hope, Stokes, Walslie, and our American
confrere, Flint, it may sqem to indicate some lack of diffi-
dence to venture another work on the subject. While,
however, we have such work as Claude Bernard, Cyon,
Thirry, von Bezold, Ludwig and Rutherford are doing in
clearing up the important subject of cardiac innervation ;
Pettigrew investigating the heart's structure and evolution ;
Brunton rigorously testing the action of remedies "upon the
heart ; Richardson pa^'ing the way for a better comprehen-
sion of the clinical significance of the heart's objective symp-
toms ; Quain searching into its pathological changes ; while
Peacock is accumulating a store of information on its mal-
formations ; and, finally, Geo. Johnson demonstrating the
changes in the arterioles in Bright's disease, and then effect
upon the heart, and thus giving force to the views of Ludwig
and Traube ; it is possible that scientific progress may have
made room for a newer treatise. In such belief the writer
lays this work before the medical public ; and, if in it many
references are made to foreign authorities to the apparent
disparagement or neglect of the workers in his own country,
it is m no such spirit, however ; nor is the work done in
England of inferior importance to the pathological researches
of the Germans, and especially their minutely exact following
out of the consequences of obstructed circulation. The im-
portance of alterations in arterial tension, and the serious
results of venous congestion have been clearly shown by
Teuton workers. The gravity of tricuspid imperfection, as

Yl PREFACE.

pointed out by Peyton Blakiston in our own country, has
especial force, given to it by recent research ; and the effect
of heart failure on the kidneys, and the production of inter-
stitial nephritis therefrom, is now more fairly comprehended.
The importance of B.right's disease in the production of heart
disease is now being fully recognized, and the crude opinions
of Bright and James are being elaborated by Traube, Ludwig,
and Geo. Johnson. The introduction of a systematic chapter
on the relation of heart disease and kidney disease to each
other is novel, and, though the writer s attention has been
directed to the subject for years past, the present chapter is
rather to be regarded as tentative than conclusive — as in-
viting more attention to the subject than suggesting the
exhaustion of it. Finally, the writer must acknowledge the
aid derived from the recent treatise on Heart Disease (Lehr-
buch von Herzkrankheiten), of Dr. T. von Dusch, Professor of
Medicine in the University of Heidelburgh, who also has
kindly permitted the use of his plates ; which, along with
others from Hindfleisch, will do much to illustrate tlie
subject under discussion.

London, August 6th, 1872.

I

CONTENTS.

Chapter I.

PAGE

The Heart — Its Evolution — ^Working — Nutrition and Blood-supply— Its
Sleep — Nerve Supply and Mode of Action 1

Chapter II. The Heart's Position, and Mode of Examining it.

Inspection — Palpation — I*ercussion — Auscultation — ^Yocal Resonance —
Aid to be derived from Arterial and Yenous Systems i 11

Chapter III. Objective Symptoms,

Palpitation — Irregularity — Intermittency — Nature — Causes — Diagnostic
Value — Prognostic Yalue 34

Chapter IV. The Gonsequences of Chstructed Circulation oMd the
Subjective Symptons of Heart Disease.

Pulmonary Circulation — Cerebral Circulation — Liver — Spleen — Kidneys
— Genito-Urinary System — Serous Membranes — Anasarca — Inability to •
Sleep in the Recumbent Posture — Symptom of Cheyne — Conclusions . . 44

Chapter V. Hypertrophy and Dilatation.

Histological Changes — Hypertrophy or Hyperplasia — Probable Mode of
Genesis — Causes or Conditions along with wliich it is found — Obstruc-
tion— Distension under Increased Pressure — Disj)lacement — Temporary
Conditions of Feebleness of Heart Walls — Niemeyer's Hypertrophy —
Lipoma ? — Traube's Thi*ee Divisions — Diagnosis of each — Inspection —
Palpation — Percussion — Auscultation — Right Side Hypertrophy — Sub-
jective Symptoms — Prognosis of each Form — Treatment — Question of
Permanency — Is Hypertrophy ever Destructive ?. , 56

Vlll CONTENTS.

Chapter YI. Affections of the Endocardium.

PAGE

Acute Endocarditis — Ulcerative Endocarditis — Chronic Endocarditis .... 96

Chapter VII. Valvular Diseases.

Aortic Obstruction — - Aortic Insufficiency — Combination of — Mitral
Obstruction — Mitral Eegurgitation — Combination of — Diseases of the
Pulmonary Valves — Tricuspid Insufficiency , 114

Chapter YIII. Diseases of the Muscular Walls of tl}£, Heart.

Myocarditis — Fatty Degeneration — Symptoms, Pathology, &c. — Fatty
Infiltration — Connective Tissue Hypertrophy — Atrophy — Amyloid
Degeneration — Syphilitic G-ummata — Tubercle — Cancer — Polypi — True 143

Chapter IX. Rupture of the Heart.
Traumatic Injuries — Displacements » 195

Chapter X. General Treatment of Heart Disease 200

Chapter XI. Affections of the Pericardium.

Acute Pericarditis — Pathology — Symptoms — Treatment — Pericardial
Adhesion — Hydropericardium, &c , 227

Chapter XII. Nervous Disorders of the Heart.

Angina Pectoris — Nervous Palpitation — Irritable Heart — Sub-Paralysis
Cordis — Hyperajsthesia — Graves' Disease — Chorea 250

Chapter XIII. Combined Heart and Kidney Disease.

Part I (1*^ Stage), From Kidney Disease to Heart Changes — Effect of
Imperfect Elimination on Arterioles — Hypertrophy of their Muscular
Walls — Effect of this on the Left Ventricle — Hypertrophy — Arterial
Distension and its Eesults— Symptoms — Physical and Psychical —
Grouping of Symptoms — Urffimia — Compensating Actions — Diagnosis
— Prognosis and Progress.

Part II {2nd Stage). Heart Failure — Effect of on Venous System —
Secondary Affection of the Kidneys — Symptoms (Old and New blended)
— Diagnosis — Prognosis and Terminations — Treatment of First Stage —
Second Stage — Kidney Disease tlie Consequence and not the Cause of
Heart Disease — Pathology and Therapeutical Indications 284

CONTENTS. I'X

Chapter XIV. Diseases of the Great Vessels near the Heart.

PAGE

The Atheromatous Process — A-ortic Dilatation — Aneurism — Symptoms —
Signs — Prognosis — Treatment 350

Chapter XV. Malformations of the Heart 360

Chapter XVI. Concluding Chapter — Elements of Prognosis

in Heart Disease.

General Elements of Prognosis — Embolism — Heart Disease in Thoracic
Deformity — Heart Disease from Chronic Affections of the Respiratory
Organs — Heart Disease and Phthisis in Young Persons — Valvular Dis-
ease and Phthisis — Clubbed Fingers — Reduplication of Heart Sounds —
Persistency of Murmurs — Conclusion 364

EERATA,

Page 7, 6 lines from to-^, for " driving," read " diving."

14, 16 lines from bottom, ybr *' ectaire," read " cataire."
45, 9 „ ,, read " branches of tlie venae cavee."

71, 19 „ ,, read " clinically " for " cbemically."

79, 5 lines from top, under Percussion, reacZ " outwards " /or "towards."
285, for ANiEMiA, read ue^MIA.

THE HEART AND ITS DISEASES.

CHAPTER I.

The Heart — Its Evolution — Working — Nutrition and
Blood-supply — Its Sleep — Nerve Supply and Mode
OF Action.

The heart is a hoJlow sphere of involuntary mtLScnlar fibre,
and in its primitive form is a mere pulsatile sac. In its
gradual evolution up the scale of creation it becomes pari
passu more and more complicated, consists of several
chambers, and has its force economised and directed by folds
or valves, which prevent regurgitation. This provision of
valves is not confined to the heart, but is found also in the
systemic veins, and in the intestinal canah In the heart the
valves are formed regionally near each other, for the heart
itself is merely a mass of involuntary muscular fibre-tubing
folded on itself. Pettigrew has shown that the heart con-
sists of seven layers of muscular fibres ; the central fibres of
the muscular wall are circular, while the fibres towards both
outer and inner surfaces pass rather from base to apex,
twisting spirally in their course. The outer and inner fibres
are continuous into each other, thus the innermost layer 1 is
continued into the outermost layer, 7, the next innermost, 2,
with the next outermost, 6, and so on. It is, as described
by B. W. Richardson, "a coiled spring" of muscular fibre,
under a beautiful nerve supply, as we shall see. These fibres
are not confined to one-half of the heart, but are mostly
common to each, like the figure of 8, only not quite so simple.
These fibres have been unwound by Shearle, Pettigrew, and
others, who show that some of them are very complex, and

B

THE HEART AND ITS DISEASES.

pass into all the four divisions of the heart. This is what
might be expected from the gradual evolution of the heart ;
as Pettigrew has shown that the right ventricle is merely a
doubling over of a portion of the primitive left ventricle. In
consequence of this community of certain fibres the heart's
contraction is almost synchronous, and has lost, to a large
extent, the vermicular action, which belongs to involuntary
muscular fibre-tubes. But still it is really vermicular, and
the synchronicity of contraction in the various fibres is
merely a rapid contraction passing from one layer of fibres
to the other, as first shown by Schiflf, and confirmed by
Valentin. The contraction commences first in the auricle,
and passes swiftly into the ventricle. The auricular con-
traction is first excited by a sensation of fulness, and its
contraction in its turn excites ventricular contraction by the
additional blood thrown into the ventricle by the auricular
contraction ; the fibres of the auricle contracting in the
dhection of the ventricle. This is the mode of action of the
working. For though a heart will continue to contract

rythmically when cut out of the body,
especially in the so-called cold-blooded
animals, still an effect is produced by
the sensation of distension, and both
Ludwig and von Bezold have found that
increased pressure within the heart ac-
celerates cardiac action, even when all
nerve branches, both of vagus and sym-
pathetic, were severed. The muscular
fibres are in bundles, the " primitive
muscular bundles," consisting of the
highest form of involuntary muscular
fibre, and have cross-markings, or are
'* striped."

This mass of muscular fibre has a peculiarity in its blood
supply, necessitated from its position and action. The
coronary vessels, as the cardiac arteries are termed, spring
from the base of the aoi*tic column, from the dilatations,
denominated the sinuses of Valsalva. Tliey receive their
blood supply, not from the ventricular systole, but from the

Fig. I.

Muscular Fil»rc ul' Heart
(from Rindfleisch).

MODE OF EXAMINING THE HEART.

trophy. Hypertrophy gives it length, and dilatation width,
while in simple dilatation there is a wide, diffused, but compa-
ratively weak impulse. In chorea, and Basedow's disease, as
well as nervous palpitation, ihe anterior chest wall vibrates
over a space the size of the palm. In some cases of right-
side dilatation and tricuspid regurgitation distinct pulsation
may be seen to the right of the sternum at the second inter-
costal space, indicating the enlargement of the right auiicle
and its increased action.

Palpation, — Palpation is the name given to the applica-
tion of the hand to the examination of the heart, and often
furnishes valuable information in addition to that furnished
by inspection. Thus palpation will corroborate the informa-
tion which we have just seen is furnished by inspection, and
it will not be necessary to repeat it. In a perfectly normal
heart the finger may be placed on the exact apex beat, which
can be felt distinctly. This admits of an instructive experi-
ment, especially in a lean person. Having placed the finger
tip on the apex beat, let the patient hold his breath. Then
we find the apex beat becoming lost, until it is ultimately
imperceptible behind the distended right ventricle. W. T.
Gairdner calls the right ventricle here a water cushion.
When the necessity for breathing comes this water cushion
can be felt passing away until the apex beat is once more
distinctly to be felt. This gives us a good idea of the tempo-
rary engorgement of the ventricles and their ready recovery,
if not too frequent and long continued, when a permanent
condition of dilatation is set up. In hypertrophy a blow-like
stroke may be distinctly felt by the hand, and a considerable
diffused heaving in hypertrophy with dilatation, while in
simple dilatation a diffused and feeble slap may be felt, often
with a struggling sensation, in the palpitation so often
found with dilatation. In fatty degeneration no apex beat
may be discernible, a significaiit fact, demonstrating that the
heart is acting feebly ; for there is something, almost inde-
scribable by words, which divides the feeble, quiet, undemon-
strative structurally diseased or atrophied heart, from the
obvious struggling of a heart dilated but structurally sound.
Palpation will also tell us of the "jogging motion " of Hope,

14 THE HEART AND ITS DISEASES.

the embarrassed heart of Bonillaud in pericardial adhesion
involving the costal plenra. Palpation gives, too, informa-
tion as to disturbances of rythm, as to palpitation, irregu-
larity, and intermittency, and in a dilated heart there is
something pathognomonic in the few, rapid, feeble strokes
preceding a halt, and then a sensation of "^ rolling over," as
the contraction again commences with a comparatively
powerful systole. Palpation, too, indicates cardiac aneurism
of the left apex by the fulness and protrusion of the inter-
costal space over the left apex on every systole, as pointed out
by Skoda, from the aneurismal portion being thrust forward.
From the application of the hand we also learn as to
epigastric pulsation from dilatation of the right ventricle,
where it is marked. There is also aortic pulsation, some-
times confounded with it, especially in the neurosal affec-
tions of the descending aorta. There is, too, a pulsation of
the liver Avhich is regarded by the Germans as of great
diagnostic importance, as indicating tricuspid regurgitation.
It is not certain how far it is due to venous regurgitation
into the portal circulation, or to impulse communicated from
the right ventricle.

The hand, too, will give further information ; as, for in-
stance, the friction of pericarditis becomes felt as well as
heard, as a thrill, the " fremissement \(^aire " or " katzensch-
nurren," and aortic stenosis will often give a perceptible
vibration or thrill. In dilatation of the aorta with roughen-
ing of the endarterium by atheroma a strong impulse with
thrill can be felt by the finger in the manubrium sterni, espe-
cially when the patient holds his head forward; and thus,
often a diagnosis can be made from aortic stenosis, whose
murmur it simulates. Palpitation of the heart is sometimes
complained of when another phenomenon is at work, viz.,
quivering of the intercostal muscles over the heart ; and the
patient may have distressing sensations, and refer them to
the heart, when the hand will detect this muscular action
quite distinct from the heart's action, which is steady and
regular. B. W. Richardson in " Discourses on Practical
Physic," gives an account of a false palpitation in an eminent
man of science. Here "the palpitation was from some

THE HEART. 5

muscular sphere from the gorged veins behind, until suffi-
cient distension is produced to awaken the sleeping auricle
and provoke contraction in it ; this, in its turn, produces suffi-
cient distension of the ventricle to provoke its contraction,
and this passes on so swiftly as to create the impression of a
synchronous contraction. The auricles, not possessing valves
behind them, are not of any great muscular strength. From
this absence of valves, a quantity of blood passes backwards
at each contraction, an arrangement which, if it existed also
in the ventricles, would make the heart of very little value
as a propelling organ, it would be of about as much effi-
ciency as a pump without valves, and that would not be
much. When, then, the ventricle contracts, the backward flow
into the auricles is, to a small extent no doubt, checked by
the closed auricle, until the auriculo-ventricular valves are
closed by the systole.

These auriculo-ventricular valves are not simple valves,
like the semilunar valves, but have tendinous cords inserted
into the ventricular surfaces ; these tendinous cords terminate
in muscular continuations, the musculi papillaries, which are
inserted into the muscular walls of the heart, and contract
with the ventricles. By this arrangement the valves are
prevented from being washed backwards into the auricle by
the ventricular systole, and are also drawn inwards, by the
contractions of the muscular terminations of the tendinous
cords. In the bird the valves are mere muscular folds,
which are lifted by the in-rush of the blood, and then take
part in the muscular contraction, forming, indeed, part of the
chamber wall. This form is found in the lower mammals, or
monotremnata, along with other bird characteristics. By
the closure of these auriculo-ventricular valves, the blood is
prevented from flowing backwards, and its progress through
the arterial openings secured. Many experiments have been
performed in order to test the perfection of these valves as
to function, or, as it is called, their competency. The best
known of these are the experiments of King, published in
1837, He found the mitral valve to be almost invariably
competent, even under a heavy pressure exercised through
the aorta, the aortic valves having been previously removed.

6 THE HEART AND ITS DISEASES.

But he found the tricuspid not nearly so resistant, a weakness
which it possesses in common with the rest of the right side
of the heart, which is ever more prone to distension than
the left side. From these experiments King evolved a theory
of a normal competency in the tricuspid, now well-known as
" the safety-valve action of the tricuspid :" an action sup-
posed to protect the right heart from over distension and
paralysis, and therefore very useful. But with all due respect
to King's experiments, and his theory, this " safety-valve
action" would simply mean a decided imperfection in the
heart, which would render it practically useless, or nearly so.
Unfortunately in practice one only sees too much of venous
engorgement due to imperfect action of the heart, and if
such an imperfection had been specially provided for us, it is
somewhat difficult to see how the race could be maintained
on the face of the earth. For tricuspid incompetency means
not only venous engorgement, but also deprival of arterial
blood to the system, and failure on the slightest call upon
the heart.

We shall see further on_, that tricuspid insufficiency is the
most serious of valve failures, and is attended with the most
deplorable consequences, and at no distant period, too.
Though the question of tricuspid sufficiency or insufficiency
is a matter of fact, and not of opinion, and therefore not to
be affected by theories about it, still King'^s hypothesis has
such a large circulation, that some remarks on it are not out
of place. The writer considered the question at length in
a paper in the '' Edinburgh Medical Journal," for December,
1870, which may be referred to, and the conclusions will be
briefly put here.

Istly. A certain amount of contraction has elapsed before
the auriculo-ventricular valve is closed, by the backward flow
of blood, and King never demonstrated that the tricuspid
was then incompetent.

2ndly. " The moderator band of Reil "* is not inserted into
the yielding wall, so as to admit more easily of the valve

* The reader will perhaps excuse the explanaticm that " the moderator band
of Reil " passes from the interventricular septum to the yielding wall in the right
ventricle, and is reaUy merely one of the columnse carnesB.

THE HEART. 7

being rendered incompetent, but, in fact, the very reverse,
being inserted at the point of insertion of the musculi papil-
laries of the outer-valve, or valve of the yielding wall, and
thus tending to secure the apposition of the valves, even in
great ventricular distension.

3rdly. That in the diving mammals, where such a pro-
vision would certainly seem indicated, all possibility of tri-
cuspid incompetency is provided against by a most powerful
right ventricle (in the dugong it is equal in size to the left,
and the heart looks " double "), with strong columnae carneae,
while the right auricle is also supported by strong tendinous
trabeculae. There is a provision for the requirements ren-
dered necessary by their aquatic pursuits, in the shape of
enormous sinuses, arterial in the cetacea and venous in the
oceanic carnivora. The theory of King is simply untenable,
and only tends to disguise the very serious nature of tricus-
pid insufficiency, as it is met with in practice. By these
different valvular arrangements, the heart is converted from
a mere muscular pulsatile sac into the beautiful, complex,
steadily working machine we find it in its highest forms,
with its muscular power directed and economised to the
utmost by these very valvular folds ; and any valvular incom-
petency at once reduces the human heart to the position of
the lower cardiac types.

In addition to these beautiful arrangements for conserving
the muscular force, the heart possesses a nervous supply
which, so far as it is yet understood, seems of an exquisitely
elaborate order.

T^he nerve supply of the heart is chiefly ganglionic, but
nevertheless the fibres from the vagus have very important
functions. For the elucidation of this innervation, it has
been absolutely necessary to resort to experiment, and the
rabbit, among other qualifications for this martyrdom to
science, possesses a very exquisite cardiac innervation. The
investigations made recently by Claude Bernard, Thirry,
Cyon, von Bezold, Ludwig, and . Professor Rutherford, have
done much to elucidate this subject. The recent lectures
by Professor Rutherford are not only the latest but the most
perfect enunciation of what is known about this matter, and

8 THE HEART AND ITS DISEASES.

his views, as found there,* will be used here to illustrate this
difficult subject. The great nerve supply of the heart con-
sists of ganglia, lying chiefly in the sulci betwixt the ventri-
cles and auricles, which are part of the great sympathetic,
and, as such, are in connection with the medulla oblongata.
By these the sensation of distension of the muscular sphere
is received, and the notice to contract evolved. But irregu-
lar contraction of the heart's fibres woidd be inconvenient,
and thus a regulating force comes in from the fibres of the
vagus. These co-ordinate the nerve force evolved by the
cardiac ganglia and the distension, so that the nerve force
evolved does not produce contraction before the chamber is
filled, neither does irregular contraction from irregular dis-
tension, that is the distension is not equal on every fibre at
first, result, but a uniform synchronous contraction of all the
fibres. The reasons for this opinion are these : 1. The heart
can beat rythmically when cut out of the body in some
animals^ and thus a nerve influence must be evolved rythmi-
cally by the cardiac ganglia. 2. Galvanizing the vagus will
delay, and, if strong, arrest the heart's contractions ; thus the
vagus possesses a retarding, co-ordinatmg action, called
" inhibitory." 3. Increased pressure on the heart from within
will induce more frequent contraction, even when all cardiac
nerves have been severed. It would thus appear that the
sensation of distension is somewhat antagonistic to, and
balanced by, the inhibitory action of the vagus, and in ordi-
nary working the sensation of distension and the evolution
of the nerve order to contract by the ganglia are controlled
by the vagus.

But in addition to this innervation come the vaso-motor
and vaso-inhibitory nerves, of which a brief and, if possible,
lucid explanation will be attempted. The vaso-motor nerves
are spread all over the blood-vessels, and are part of the
ganglionic system. The arteries in a white-eared rabbit can
be seen to alter their calibre, and that somewhat rythmically,
and changes in the calibre of veins have been observed.
Section of the cervical sympathetic in the neck, it is well

* See " Lancet " for 1871—1872.

THE HEART. 9

known, leads to paralysis and distension of the vessels of the
head, i.e., their semi-contracted normal condition cannot be
maintained after section of the sympathetic trunk, with which
their vaso-motor nerves are connected. These vaso-motor
nerves seem to possess a vaso-motor centre lying betwixt
the corpora qnadrigemina and the calamus, and irritation
here will produce vaso-motor spasm generally, and, from the
opposition offered thus to the blood stream, excited actioij of
the heart and palpitation. The vaso-motor nerves have
also inhibitory nerves, i.e., nerves which counteract the vaso-
motor nerves and relax the blood-vessels by suspending the
action of these vaso-motor nerves. The inhibitory nerves
are connected with tlie vagus, and in the rabbit this section
forms the superior cardiac nerve. This nerve seems also the
'' sensory nerve " of the heart. Certain nerve fibres of the
heart pass to the endocardium and record over-distension.
Cyon found that by passing a stream of serum through the
heart so arranged as to be able to add carbonic acid, to the
serum, and cut if off again at will, that the carbonic acid para-
lysed the heart, audits contractions ceased, but were resumed
when the carbonic acid was cut off. This all tends to show
us something of the beautiful nerve arrangements by which
the circulation is regulated and balanced. The heart becomes
distended to a perceptible degree, and its sensory nerve being
also the vaso-inhibitory nerve, this distension leads to the
vaso-inhibitory action being put in force, and the vessels of
the peripheral circulation become dilated. This at once leads
to diminished arterial pressure, being equal to so much
increase in the arterial system in capacity to hold blood, the
ventricles are relieved by this, and the distension of the heart
is remedied. Not only does this occur, and exercise an
immediately relieving effect, but this vaso-motor inhibition
extends to the vessels of the coronary circulation, and thus a
freer blood supply is furnished to the heart walls, and hyper-
trophy, giving greater power to withstand distension, which
is equivalent to being able to more completely contract and
empty themselves, results. The correct appreciation of this
double innervation of both heart and blood-vessels will be of
great importance in aiding a more thorough understanding

10 THE HEART AND ITS DISEASES.

of various morbid actions, as well as a more perfect compre-
hension of the causation of hypertrophy.

The two muscular ends of the circulation, the central
accumulation mto one mass, the heart, and the general peri-
pheral distribution, the arterioles, are thus balanced in an
exquisite manner, and maintain a blood equilibrium, by acting
and reacting in a manner which must excite the admiration
of all, while this mutual reaction can so act and react as long
to avert disturbance of balance in the circulation — a subject
the importance of which will become more and more appa-
rent as different diseased conditions come under our notice.

MODE OF EXAMINING THE HEART. 11

CHAPTER II.

The Heart's , Position and mode of Examining it — Inspec-
tion — Palpation — Percussion — Auscultation — Aid

DERIVED from ArTERIAL AND VeNOUS SYSTEMS— YoCAL

Resonance.

The position of the heart in the thorax may be rudely de-
scribed as extending from the second right intercostal space,
under which is the right auricle, to the fifth left intercostal
space extending as far to the left as the nipple, where the
left apex may be felt. It alters somewhat with the position
of the body, and with deep inspiration and expiration, so far
as its limited bounds will permit. Enlargement gives it a
tendency to fall down somewhat, probably simply from its
increased weight. Placed thus in a comparatively fixed
position, certain relations to other points are so fixed that
we can refer to them in speaking of the heart, as, for
instance, its apex beat being in the fifth intercostal space,
the sound of the aortic valves being heard in its maximum
intensity at the articulation of the right second costal carti-
lage, the pulmonary sounds at the third left costal cartilage,
and the tricuspid at the ensiform cartilage ; or again, that
the left auricle lies behind the third rib and the second and
third intercostal spaces. Occupying such a position in the
thorax, it admits of being examined by inspection, palpation,
percussion, and auscultation.

Inspection, — -Inspection tells us how far the patient's
physique is good ; how far the thorax is well formed ;
whether the intercostal spaces are widened or narrowed
by inspiration ; whether each side of the chest is playing
well, and the movements of respiration symmetrical. In
making this inspection a good light is required to give
more than mere negative information as to the heart itself;
consequently the patient should face the light, a position
which will also put the medical man's face in the shade, a

12 THE HEART AND ITS DISEASES.

matter often of some importance. When the light thus fahi^
on the thorax a faint movement may be seen at the fifth
intercostal space, synchronous with each radial pulse. In
very thin persons, especially if under excitement, this move-
ment may extend over a space the size of the palm of the
hand.

Inspection will also give us information as to various
morbid or abnormal conditions, as follows : — In many cases
of heart disease, especially where there is hypertrophy, there
is a protrusion of the thoracic wall over the region of the
heart. This is very common in young persons before the
costal cartilages are set. We also can see at other times an
epigastric fulness from depression of the diaphragm due to
increased weight within the pericardial sac from effusion or
enlargement of the heart itself. The intercostal spaces may
be seen bulging in pericardial effusion, while a retraction
may be noticed when pericardial adhesion has glued the
heart to the costal pleura of the anterior chest wall. Another,
not so well known consequence of pericarditis, viz., para-
lysis of the diaphragm from the inflammation affecting
the phrenic nerves, may be detected by inspection. Here
in inspiration there is not normal fulness but retraction,
and on expiration not retraction but protrusion ; the dia-
phragm no longer taking part in the respiratory movements,
but merely being affected by them.

As to the heart itself, inspection will give us information
often as to its position ; as, for instance, when enlarged, it is
apt to fall a little, or the apex beat to be lower from the
elongation of hypertrophy. The heart, too, may be displaced
to the right side by left side pleurisy, by retraction of the
right lung, mediastinal tumour, or enlargement of the left lobe
of the liver. It may be too much to the left from right side
pleurisy, left side lung-retraction, and frequently from enlarge-
ment of the liver. The heart's action is also, to some extent,
recognisable by inspection, and in fatty degeneration of the
heart itself, in atrophy, and in pericardial effusion, the apex
beat is invisible. In hypertrophy there is a forcible blow,
especially when there is some dilatation with great hyper-
trophy, as in aortic regiu'gitation and in right-side hyper-

THE HEART. 3

aortic recoil or aortic systole. The explanation of this is
obvious, for were the coronary circulation to receive its blood
supply from the ventricular systole, it would receive that
blood supply at the most unfavourable time, namely, the
period of muscular activity, when the muscular contraction
would oppose the entrance of the blood. Instead of this it
receives its blood supply from the aortic recoil, and during
its own diastole, or period of muscular flaccidity. For a
proper recognition of this fact and its bearing, as we shall
see, on a very common valvular lesion, aortic regurgitation,
we are indebted to Mauriac. The elastic aorta is distended
by the ventricular contraction and recoils by virtue of its
own elasticity ; the flow of blood backward into the ventricle
is arrested by the closure of the aortic semilunar valves, and
the blood passes into the coronary vessels from the aortic
pouches of Valsalva. This is one of the peculiarities in the
cardiac circulation of great importance to the continuation of
its action. Another is the manner in which the coronary
veins open into the venous circulation. This is effected by
their passing obliquely through the wall of the right auricle,
forming the Foramina Thebesii. By this oblique perforation
regurgitation is, to a very great extent and normally, com-
pletely prevented. The same arrangement exists in the
mode by which regurgitation into the ureters from a dis-
tended bladder is prevented. This peculiarity was pointed
out by Wardrop, who showed its importance in preventing
the heart from being paralysed by a reflux of venous blood,
charged with carbonic acid, when already suffering from
right-side distension or engorgement. For not only would
the carbonic acid have acted as a direct paralysing agent,
but the venous blood gorging the coronary veins, would
obstruct the flow of arterial blood coming in by the coronary
arteries. The muscular contraction of the heart compresses
all the smaller vessels within its structure, and empties their
contents into the coronary veins, which, in their turn, convey
the blood into the right auricle during the auricular diastole,
which commences ere the ventricular systole is over. The
mode by which the veins perforate, secures the cardiac circu-
lation against venous regurgitation, and when the muscles

B 2

4 THE HEART AND ITS DISEASES.

become flaccid behind the aortic valves, the blood in the
aortic systole finds the cardiac circulation empty ready for
the flow of blood into its relaxed muscular structure.

During this diastole the heart-structure is not only being
supplied with pabulum, and its integrity maintained by nutri-
tion fi'om a free vascular supply, but also it is now enjoying
its brief, fitful sleep. In its incessant round of labour no long
repose is compatible with the continuation of the existence
of the organism. It must not, however, be supposed that
the actual amount of sleep enjoyed by the heart is small ;
that would be incompatible with its active function. The
diastole is much longer than the systole, and Marey, from
cardiographic tracings, calculated the systole to occupy no
more than one-fifth of each cardiac revolution, while the
remaining four-fifths, the diastole, are devoted to sleep and
to feeding.

From Professor Traube's tracings, with his new improved
cardiograph, the writer feels inclined to think this calculation
of Marey's very nearly correct. The heart then, at a rough ^

estimate, sleeps no less than 19 out of the 24 hours. But
the auricles sleep even more, and their thin walls have com-
paratively long periods of rest. The thicker ventricles have >
a longer period of activity during each cardiac revolution.

This calculation of Marey's is formed from a normal and ^

slow pulse. When the pulse rises, there are so many more
contractions, or systoles, each minute, and as this increase of
frequency takes place at the expense of the diastole, i.e., the
duration of each systole is but little^ if at all, affected by
increased rapidity in the ventricular contractions, and con-
sequently the heart's sleep is infringed upon. Increase in
the rapidity of the pulse tends to exhaust the heart by dimi-
nishing not only its sleep, but equally the time during which
it is receiving its nutrition. Thus the difference betwixt a
pulse of 72 and a pulse of 144 is, that in the one case the
heart sleeps and feeds four-fifths of its time and works one-
fifth, and in the other the sleeping time is reduced to three-
fifths, while the working time is two-fifths. This is a very
serious difierence in an organ whose labour is so incessant.

During this brief sleep, the blood is pouring into tlie flaccid

MODE OF EXAMINING THE HEART. 15

pulsating action immediately below the heart; it was epi-
gastric, and had no relation to the heart."

Percussion. — This is one of the most important means of
ascertaining the condition of the heart, so far as its size and
shape at least are concerned. But percussion is surrounded
by many difficulties and sources of fallacy, and requires the
greatest care and circumspection in its performance. A small
portion of the heart is alone in direct contact ivith the chest
wall forming a rudely triangular space, varying in size on
inspiration and expiration. A deep inspiration will so inflate
the lungs as to bring down the thin edge of the lungs
further over the heart, while a full expu'ation permits more
of the heart to come in contact with the chest wall. It
follows from this that the lungs may interfere very much with
the area of cardiac dulness by increasing it in cirrhosis of
the lung, for instance, and diminishing it in emphysema, or
when the left lung is turned down over the heart by an
adhesion to the costal pleura. From this area of complete
dulness the lung interferes and grows rapidly thicker, so that
the outline of the heart itself is well covered by lung, and
gives only deep-seated dulness. Practice and patience will
alone endow a man with power to estimate, fairly correctly,
the outline of the heart by percussion, and by no other
means can it be done at all. The knowledge is well worth the
trouble required to attain it. In order, then, to learn some-
thing really valuable, as this information is, viz., how to map
out a heart, and also how to learn that very useful auxiliary
to percussion, the sense of resistance, perfectly indescribable
by words, I can recommend to the beginner the following
plan : — Take patients with presumably healthy hearts, and
with a thorax not too much covered with either muscle or
fat, and first ascertain the exact apex-beat with the finger
tip. Then draw on the skin a heart about the size of a
closed fist, making the right auricle come up to the second
right costal cartilage, which will give about the correct posi-
tion and size of the normal heart. Thus the student will
have a guide to the interpretation both of the sound elicited
and the sensation of resistance oflered. The gradually more
deep-seated dulness of the upper border will be better ap-

16

THE HEART AND ITS DISEASES.

praised, while tlie outline of the lower border, in close appo-
sition to the liver, will be more clearly distinguished from
the liver-dulness immediately beneath it, for the heart is
merely separated from the liver by the diaphragm and some
serous layers of no great thickness. If this plan is not
satisfactory to the reader it is to be regretted, but really I
can communicate no secret for a more easy method of
acquiring a solid knowledge of percussion in defining the
heart. In order to assist him the following plate is copied
from von Dusch's, the most recent German book : —

Fig. II.

Outline of Heart-Pcrcussion-Dulness, of Complete Dulncss, and of
Apex-beat (in the recumbent posture on each side).

a h, line of diaphragm ; d d! d", outline of heart-dulness
when lying on the back ; h I, limit of dulness Avhen on the

MODE OF EXAMINING THE HEART. 17

right side ; m n^ ditto on left side ; I V l'\ limit of complete
dulness when on the back ; I f g, ditto when on the left side ;
Ice, ditto when on the right side ; ^, point of apex-beat
when on the back; i', ditto when on the right side ; i" , ditto
when on the left side.

This will aid much in attempting to learn percussion, the
value of which increases much with the increasing skill of
the percussor. When sitting or standing, the heart will be
a trifle lower than when in the recumbent posture. Having
become fairly acquainted with the normal heart, as indicated
by percussion, the difference in size and shape in it will not
present so much difficulty in their recognition. Thus in left-
side hypertrophy the dulness will extend downwards, with-
out great increase in width, and more to the left, merely an
extension of the left ventricle outwards and downwards.
Right-side enlargement will increase the boundary of the
lower edge and extend it over the 3rd, 4th, and 5th right
costal cartilages. General dilatation of the heart is rather
globular than pointed, while pericardial effusion is pyramidal,
with the base downwards, and becomes broader in the hori-
zontal posture, and narrower when upright.

It will now be necessary to point out some of the sources
of fallacy, the different circumstances which interfere with
the indications of percussion, and lead to error. A variety
of different conditions militate against the absolute accuracy
of the information derived from percussion, and a brief
resume of them may be of service.

Firstly, as to the different morbid conditions which will
be liable to mislead us by increasing the apparent side of the
heart. Retraction of the lung by bringing a greater portion
of the heart in close contact with the chest, will apparently
add to the heart's dulness, but that will only extend to the
area of complete dulness. Consolidation of the lung by
pneumonia, or tuberculosis, will add to the heart's apparent
size. In addition to these are pericardial effusions and
thickenings, aneurism of the ascending aorta, substernal
abscess, tumours in the anterior mediastrium, simple or
malignant, a thymus gland still remaining, pleuritic effusion,
more so if limited by adhesions, &c. Fat or thick muscles

C

18 THE HEART AND ITS DISEASES.

will, on the outside of the chest, more or less interfere with
the percussion ; and in females the left breast is sometimes
in the way.

The heart-dulness is lessened by atrophy of the heart
itself, or congenital smallness, by an emphysematous con-
dition of the lung, or by the lung being bound down over
the heart by a pleuritic adhesion. Deep inspiration will
reduce the area of complete dulness, while change of position
will alter the limits somewhat. In pneumopericardium the
heart's area becomes tympanitic.

When taken along with the information furnished by
inspection and palpation, percussion becomes a valuable addi-
tion to our means of examining the heart, and its sources of
fallacy will be fairly eliminated in the great majority of cases
by the aids derived from the other measures, and even more
by the information furnished by the remaining means of
examining the heart, viz., auscultation, a method practised
immediately, for some time before Laennec added so much to
its importance by the use of a mediate agent, the stethoscope.

Auscultatio7i. — This last is the most beautiful and most
perfect means we possess for ascertaining the condition of
the heart. By it we can read more exactly the conditions of
enlargement with which we have been made acquainted by
the previous measures ; we can interpret how much dilatation
exists, and with how much hypertrophy combined ; how far
the heart is equal to its work by the perfection of its rythm ;
how its valves are working ; if obstruction Exists ; if regur-
gitation be present. " We can ascertain very often on what
that enlargement depends ; we can feel, as it were, the struc-
tural condition of the heart itself. But to enable us to do all
this by auscultation, we must first make ourselves certain,
as far as we can, of the sounds in health, their modes of
origin, and the conditions which alter them. The heart's
sounds are two, the first and second sound, so-called from
the order of time in which they occur in the cardiac revolu-
tion. The first is the systolic sound, accompanying the ven-
tricular contraction ; the second is diastolic, or heard during
ventricular flaccidity. Betwixt these two is a pause, very
short, but still distinct. After the second sound, and before

MODE OF EXAMINING THE HEART. 19

the next systolic sound, comes a longer pause. The pauses
and sounds are nearly proportioned to each other, the long
pause precedes the long first sound; the short pause precedes
the short second sound. Supposing the dotted lines to repre-
sent the pauses, and the unbroken lines the sounds, we find

each cardiac revolution to consist of - - . In

order to thoroughly comprehend this, we must just go shortly
over the heart's action, which is to deliver its contents into
the arteries. Thus during the long pause, or period of rest,
the blood is rushing from the veins into the heart's chambers
inaudibly ; nor is the normal auricular contraction audible.
On systole or ventricular contraction we have the first or
long sound produced ; a short pause, and then the recoil of
the elastic arteries drives together the semilunar valves,
causing the short, sharp, second sound of valve closure.
This is the cardiac revolution, and now we must see how
the first sound is produced.

The production of the first sound has been the subject of
an immense amount of discussion, which it would be needless
to review here. It is now generally admitted that the first
sound has two factors, the chief factors, and other smaller
auxiliaries. The two chief factors are muscular contractions
of the walls, and closure of the auriculo-ventricular valves.
In order to get a good conception of the character of muscu-
lar sound, the student can first apply the stethoscope over
the heart. Take the character of the sound, and then apply
the stethoscopes over the ball of the thumb, and put the
muscles of the thumb into action rythmically. This can be
done without any movement of the skin and friction on the
stethoscope, which would be a source of error.

A little of such practice will soon enable the young aus-
cultator to distinguish for himself the character of muscular
sound more perfectly and clearly than any amount of reading
could teach him. Having learned to distinguish the character
of muscular sound, he will soon be able to distinguish the
other chief factor, the sound produced by the flapping to-
gether of the auriculo-ventricular valves. This is a "slapping"
sort of sound, approaching the character of the second sound.
In hypertrophy of the muscular walls, the muscular sound is

. c 2

20 THE HEART AND ITS DISEASES.

often predominant, giving a dull, mnffled sound, while at
other times, as in dilatation, the thin wall emits bnt a thin
mnscular sound, and the flapping together of the auriculo-
ventricular valves is the predominant sound. In hypertrophy
with dilatation sometimes the valves are so forcibly driven
together as to produce a " clanging " or " ringing " sound.
The sounds are altered by thickening of the free edges of
these valves, or by great thinness. In addition to these two
chief factors must be added a third cause of sound, viz., the
blow of the heart's apex against the chest wall. This is
attributed to the recoil of the heart on expelling its contents,
like the rebound of a musket, but it seems more probably to
be due to the elongation of the arteries, and especially of
the aorta, on distension by the ventricular contraction. In
addition to these the Germans attach much importance to
the rushing of the blood through the aortic and pulmonic
orifices, as a factor in the production of the first sound.

These sounds go to make up the first sound, and may be
fomid with one or other preponderating. The blow of the
apex against the thoracic wall is often very apparent, from
the impulse communicated to the stethoscope, more so indeed
than to any impression it makes on the internal ear, as the
other causes of sound will generally be increased along with it.
The first sound may become almost entirely lost in fatty de-
generation, or may approach the second sound in character.

The second sound is now attributed entirely to the
closure of the semilunar valves. The sounds of the aortic
valves are stronger and thicker than the pulmonary valve-
sounds, and can be distinguished from the pulmonary sounds.
The aortic sounds can be most dis.tinctly heard at the articu-
lation of the second right costal cartilage with the sternum ;
at this point the aorta comes nearest to the anterior chest
wall from behind the pulmonary artery. The pulmonary
sound is best heard over the third left costo-sternal articula-
tion, and is only heard at this point very commonly. These
sounds are normallA^ heard over very limited areas, and mav".
with a little care be readily distinguished : the aortic sound
fuller and stronger, the pulmonary sound sharp and clear.
Obstruction to the blood-flow accentuates these sounds, and

MODE OF EXAMINING THE HEART. 21

this accentuation is often of great diagnostic value. In
Bright's disease the aortic sound is ever increased, and any
pressure or obstruction in the aorta itself will cause it. But
it is in the pulmonary second sound that the accentuation is
diagnostically most important ; all obstruction to the pul-
monic circulation, as in extensive lung disease, congestion,
whether simple or arising from left side incompetency, be-
comes audible by accentuation of the second sound. Skoda
first pointed this out, and showed its importance as a means
of estimating the amount of mitral disease. Accentuation of
the pulmonary second sound is pathognomonic of stress on
the right ventricle, however produced. It is almost always
an indication of enlargement of the right side of the heart.
As we proceed to the discussion of various morbid conditions,
the reader will see the great importance of alteration of the
second sound, and the diagnostic importance of his being able
to distinguish any variation in the character of this sound.

Murmurs. — The alterations in the sounds of the heart are
all-important, but diagnostically their being supposited, or
merely marked by a murmur, is of the greatest moment.
Murmurs are differently produced, and are of two kinds,
the obstructive and the regurgitant. The obstructive mur-
mur is produced by the blood being forced over a roughened
orifice, or a narrowed orifice. It is thus of a rasping or
sawing character, and often not uidike a fine saw going
through a piece of soft wood. The obstructive murmur is
usually significant of stenosis, and may be found at the
arterial orifices, and at the mitral valve not uncommonly,
but tricuspid stenosis is practically unknown. The regur-
gitant murmur is produced by reflux, or regurgitation through
a valve which is no longer closing perfectly, and cutting off
the backward flow of blood. It is a soft murmur as compared
to an obstructive murmur, and is usually of a blowing sound,
especially in auriculo-ventricular regurgitation. It may be
found at any of the four cardiac orifices, by far the most
rarely at the pulmonic orifice. Sometimes the valve becomes
both narrowed and incompetent, and then we have a double
murmur consisting of both obstructive and regurgitant mur-
murs, the regurgitant following the obstructive. Murmurs oc-

22 THE HEART AND ITS DISEASES.

curring during ventricular contraction are termed systolic; dur-
ing ventricular rest they are termed diastolic, and are connected
with imperfectly arrested backward flow on arterial recoil.

Thus we find that systolic murmurs are four; dia-
stolic two. The four systolic murmurs are of two classes,
obstructive and regurgitant. During the ventricular systole
murmurs may arise either at the arterial orifices, obstructive
murmurs, or from auriculo-ventricular insufficiency, regur-
gitant murmurs. These murmurs are all isochronous. It is
obvious then that other means must be invoked to determine
which of these four a systolic murmur may be. These are
two : 1. Character of sound, not very trustworthy at all
times ; and 2. Position of maximun intensity, of very con-
siderable aid in diagnosis. The obstructive murmur is
harsher, usually more pronounced, and heard over a greater
area. The regurgitant murmur is softer, more blowing, and
heard over a more limited area.

But in so speaking, it must be understood that the typical
murmur is being here described. For murmurs run into each
other, exist together, may be heard over greater or lesser
areas, are congenital, intermittent, and are at times in various
ways perplexing. But ordinarily they may be as fairly
relied upon as any other diagnostic means we possess.

Then as to position, it is obvious that each valve may
have two distinct forms of disease, and consequently two
murmurs, which may occur separately or combined. But the
period at which heard, prevents this from being confusing.
Each orifice has then an area over which its murmurs are heard
with greatest intensity. As a crown piece would cover the
four valves of the heart, it is obvious that position of maxi-
mum intensity would be rather uninstructive and confusing,
than tending to throw light on the subject, if it were not
that each murmur radiates a little outwards, according to
what the late Hyde Salter called " conduction " and " con-
vection." This radiation makes position of maximum inten-
sity a point of great importance in estimating which of the
four systolic murmurs we have got to deal with.

Thus an aortic systolic murnrur is heard a little way from
the aortic valves, and is most distinct where the aorta curves

MODE OF EXAMINING THE HEART.

23

forward towards the sternum, {.^..tlie second right costo-sternal
articulation. The pulmonary systolic murmur is heard very
closely over the. valves, as the artery soon curves from the
sternum, and is in its maximum intensity at the third left
costo-sternal articulation, and usually only heard at this point.
A systolic murmur heard in its greatest intensity towards
the left apex, and even further to the left, an inch even
behind the nipple sometimes, is mitral regurgitant. It is
often heard over a much larger area, but that is the area of
its maximum intensity, and commonly it is conhned to that
area. A tricuspid murmur is only heard, and that too faintly,

Fia. III.

Aortic Valves

Pulmonary Valves.

24

THE HEART AND ITS DISEASES.

over the ensiform cartilage. These diiferent areas are
well marked and illustrated by the accompanying plate.*

These four murmurs then, can be arranged according to
these different means of distinguishing them, so as to make
then' distinction not very difficult.

Valve.

Murmer.

Time.

Character.

Point of maximum
intensity.

Mitral.
Tricuspid.

Aortic.
Pulmonary.

Regurgitant.

Ditto.
Obstructive.

Ditto.

Systolic.
Ditto.
Ditto.
Ditto.

Blowing.

Ditto.

Rasping.

Ditto (fine).

Left apex, to tlie left.

r Limited to ensiform
\ cartilage,
r Second right costo-ster-
\ nal articulation.
J Third left costo-ster-
\ nal articulation.

These are the systolic murmurs which mark, or obliterate
the first sound ; they are more or less common, the mitral
and aortic most frequently met with, and then the tricuspid,
the pulmonary being very rare. It is obvious that the rela-
tive frequency has nothing whatever to do with the diagnosis,
but it has sometimes a value, especially in guiding a tyro,
who usually finds more rare murmurs during the earlier part
of his diagnostic education than he does later on, when his
diagnosis is more perfect.

Lesions heard during the time of the heart's second sound
are necessarily regurgitant through the semilunar valves,
and may be either aortic regurgitant, very common, or pul-
monary regurgitant, very rare. The regurgitant murmur is
always heard over the base of the heart, and often also
towards the apex, and extends over the third, fourth, and
fifth costal cartilages and corresponding portion of sternum.
The aortic regurgitant murmur is then diastolic, and that
almost establishes its position, and renders its recognition
almost independent of the character of the sound (blowing,

* This plate is taken from Da Costa's well known work on ** Medical
Diagnosis," with a slight alteration to meet the writer's views as to tlie position
of the pulmonary valve-sound. Da Costa places it over the second left costo-
sternal articulation, wljile the writer agi-ees with W. T. Gairdiner in placing it
over the third left costal cartilage.

MODE OF EXAMINING THE HEART. 25

or perhaps harsher), and of its area. The diagnosis of a
pulmonic murmur from an aortic murmur when regurgitant
is difficult, and it is fortunate that practically the question
resolves itself into one of relative frequency. (For the re-
quirements of diagnosis here, the reader must look to the
chapter on Valvular Lesions.)

During the time of ventricular inactivity, two other
murmurs are heard, viz., mitral and tricuspid obstructive
murmurs. These were once described as diastolic murmurs,
and we are indebted to W. T. Gairdiner for first clearly
pointing out that they are not diastolic truly, but, in fact,
presystolic murmurs. That is, they are caused by the pre-
systolic auricular construction, and run into the first sound.
Here, then, are theoretically two murmurs, but practically
only one, for tricuspid obstruction has not yet been satisfac-
torily diagnosed in life, and in two cases occurring to such
accomplished diagnosticians as Bamberger, and W. T.
Gairdiner, in each case there was a tumour pressing on the
right aiuicle, and not a tricuspid stenosis, as supposed.

The mitral obstructive murmur as heard over the left apex,
is presystolic, sawing, and not to be confounded with any
other murmur practically. Thus really the number of
murmurs is not so very confusing for the beginner, and most
murmurs are single. The difficulties are not so great as to
be discouraging, and a little careful attention will usually
suffice to read this language of murmurs, and in a little time
the student will be able to interpret pretty correctly the
double or combined murmurs, whether both obstructive and
regurgitant at one orifice, or the two murmurs belong to two
separate orifices. Some murmurs, depending on curious con-
genital malformations, and on aneurism of the ascending
aorta, or when a diseased valve is so associated, will tax the
diagnostic skill of any one, from the redoubtable Skoda
downwards, and the beginner should not be deterred by
meeting with such a case early on. Neither should he lose
faith in murmurs from finding no lesion after a very decided
murmur, for Skoda has pointed out the origin of murmurs
in irregular action of the musculi papillaries, where, naturally
enough, no lesions are found. Lesions, too, are sometimes

26 THE HEART AND ITS DISEASES.

found which gave no sign during Hfe, and this is especially
the case with lesions of the left side when tricuspid failure
co-exists. It seems here, too, that the small amount of blood
propelled through the heart is insufficient to cause a murmur
at a narrowed orifice.

Murmurs, too, will intermit and be very perplexing, and
even an aortic regurgitant, the most constant of all, will
sometimes become inaudible.

Anoemic murmurs are usually aortic, but may be mitral.
Peacock says that anoemia will often magnify an organic
murmur in a rather perplexing manner. On the other hand,
murmui's will often become audible when the heart's action
is improved by treatment, which were previously inaudible,
and as the heart sounds become more distinct, murmurs will
often become audible as well.

A murmur resembling a musical note is sometimes found,
and is supposed to be due to a shred of lymph hanging
from the free edge of a valve and vibrating in the blood
current.

Aid derived from Ao^terial System. — This will often afford
us useful information, as the elastic arterial system, while
healthy, gives out very accurately the impression made upon
it by the heart. It is somewhat customary, too, to feel a
patient's pulse early in his examination, and before physi-
cally examining his chest, and therefore the indications
derived from the arterial system are very useful, and may
give us the direction, at least, in which to conduct our
examination. Its frequency generally first attr^-cts our
attention, and the counting of the pulse by the watch was
the first attempt to aid our diagnosis by an instrument.
This mere frequency is often suggestive, especially if it be
found to remain, and not be merely the result of nervousness
on the part of the patient. Great frequency is not a pleasant
symptom, while unusual slowness is usually neurosal. But
the frequency is of small moment usually as compared to its
strength or force. This is usually in proportion to the ven-
tricular impulse, and at once establishes a step towards the
diagnosis. Thus it is full and strong in hypertrophy and
weak in dilatation and fatty degeneration. Rythm is very

MODE OF EXAMINING THE HEART. 27

important, when good, giving a fair presumption of power
in the heart ; when irregular and even more intermittent it
is of bad omen, but this may occasionally be neurosal. Some-
times a pulse is delayed, especially in elderly people, and
the radial impulse is distinctly behind, and not synchronous
with the ventricular systole. Then a pulse will sometimes
be '' full," but not hard and incompressible. This indicates
vaso-motor inhibition and a dilated state of the vessels ; the
opposite condition of small, " wiry," incompressible pulse is
connected with vaso-motor action and a contracted state of
the vessels, very marked in hysterical palpitation and in
abdominal inflammations. At times the real rate of pulse is
somewhat masked, and it will give an apparent rate, not
borne out by counting it ; thus there is a quick slow pulse,
^.^., appearing quicker than it is, and a slow quick pulse, i.e.,
being quicker than it appears to be. Then a pulse may be
hard and incompressible, that is, pressure with the finger
cannot obliterate it ; here there is usually left side hyper-
trophy ; at other times, in cardiac debility, or in anoemia,
the pulse at the wrist is easily obliterated. It must be borne
in mind that atheroma magnifies the ventricular impulse, and
gives a heave to the pulse ; this is well seen in the temporal
artery when, sinuous and rigid, it is distended by ventricular
systole and becomes widened and elongated. Of course
atheroma is usually accompanied, in the earlier stages at
least, by hypertrophy of the left ventricle, and thus the ven-
tricular systole is strong and sustained. This combined
condition is often misleading in conditions of temporary
sickness. In' a near relative of the writer's this condition
existed, and even during physical depression, even when
tonics and stimulants were really needed, the strong radial
pulse from a hypertrophied left ventricle and atheromatous
arteries almost seemed to indicate venesection. At times of
greater depression, as after acute diarrhoea, a distinct inter-
mission could be felt, apparently quite out of place in such a
pulse, but really indicating correctly the passing condition.
This effect of atheroma, or the impression created by a pulse,
is well worth noting, and will often be found useful in
practice.

28 THE HEA.RT AND ITS DISEASES.

The pulse is often very significant of a valvular lesion ,
and will sometimes be sufficiently mai'ked to aid much in
diagnosis ; thus, in aortic obstruction it is small, but sus-
tained, from the hypertrophy which accompanies such
obstruction. In aortic regurgitation it is " splashing," or
" like balls of blood shot under the finger," the arterial dis-
tension being great from the hypertrophied and dilated
ventricle, but unsustained, by reason of the failure in the
semilunar valves ; in mitral obstruction it is small and
regular, not sustained, as in aortic obstruction, while in
mitral regurgitation it is irregular in volume, that is, the
pulse varies in volume markedly, one beat being full, and the
next small, depending upon the varying amount of blood
which passes back through the imperfect mitral valve at each
systole. This must not be confounded with the irregularity
in time, the unrythmical pulse of dilatation, though both may
occiu' together. In right side disease the pulse is ever small,
and when right side failure co-exists, the pulse is less cor-
rectly significant of each left side condition, and possesses a
general character of smallness. The right side really empties
at every stroke so much of the blood in the veins through
the lungs into the left heart, which transmits it more power-
fully on into the arteries. But though the left side is so
strong, it cannot affect the bulk of blood passed over to it by
the right side ; any defect in the original lifting pump is felt
all over the distribution of the vessels, and a leak in that
pump affects the volume in the most distant distribution.

The radial pulse will often alone tell us that in a heaving,
strongly-acting heart, with a small pulse, the hypertrophy
and action is in the right ventricle, and not the left ; for
equal action in the left would not be without effect on the
radial pulse. This right-side hypertrophy is compensatory
to some morbid action lying betwixt it and the radial pujse,
and is neutralized thereby, as by some disease of the lungs,
pulmonic circulation or left heart. The pulse, too, is affected
by anoemia, and when anoemia is present, the pulse cannot
faithfully reflect the impulse of the heart.

The arterial system will also convey murmurs, and the
murmur of aortic obstruction may be distinguished in the

MODE OF EXAMINING THE HEART. 29

carotids, brachial, and femoral arteries. Murmurs will be
created in arteries by pressure on them by a tumour, or the
stethoscope itself, and every arterial murmur is not indicative
of aneurism, when not cardial, but may depend on other
causes, or be created by the mode of examination. Arteries
when numerous possess a souffle, as heard in the placental
or utero-placental souffle, in an enlarged thyroid gland, by
dilated arteries, in Grave's, or Basedow's disease. The wide
dilated aorta often found with atheroma has a murmur,
caused by its roughened atheromatous interior, and this
systolic murmur may not only be readily heard, but felt by a
finger on the manubrium sterni. Here, especially when the
patient thrusts his head forward, a thrill can be distinctly
felt, along with the huge, long heave of the dilated, thickened
vessel.

A subclavian murmur is often heard, especially in labouring
men, which may be aneurismal, but is more often due to
tubercular infiltration of the apex of the lung, or, as
B. W. Richardson thinks, due sometimes to pressure of the
subclavius muscle.

Aid derived from the Venous System. — The venous system
furnishes us also with valuable information, even to the first
sight in the cyanotic condition of venous congestion. In
failure of the heart, especially when the right side is yielding,
the veins are too full of blood, or, as the Germans say, the
blood is lying too much on the venous side. Betwixt the
two muscular terminations of the system the blood lies, and
in health a balance is maintained by means of mutual adap-
tation, but in heart failure this becomes disturbed ; the
elastic arteries with the arterioles and strong left ventricle
pass the blood out into the veins more easily than the right
heart takes it out of the veins ; thus the venous side is con-
gested, and, the bulk of blood remaining the same, the
arteries are less full than in health. For the venous system,
lying betwixt the systemic capillaries and the pulmonic
capillaries, has the right heart for its pump, its propelhng
power, with some auxiliaries it is true ; while the arterial
system, extending from the pulmonic capillaries to the sys-
temic capillaries, has for its pump the left ventricle. Failure

30 THE HEART AND ITS DISEASES.

in the right ventricle then means an imperfect emptying of
the venous reservoirs and venous congestion. This is visible
in the colour of the complexion, lips, &c., and the change in
colour is of great diagnostic importance. It is more marked
in acute attacks of cardiac asthma, or dyspnoea, and passes
away to a great extent with the attack. Persistent cyanosis
not congenital is ever of bad import, and indicates great
debility in the right ventricle. Venous fulness varies with
respiration ; when the breath is held the veins fill, that is,
the arterial system is passing its blood out into the veins
faster than the right heart is emptying the veins of blood,
the circulation through tJie lungs being greatly impeded by
the arrest in the respiration. A few full breaths, the deep-
sighing respiration which follows, soon restore the vascular
equilibrium, and the venous fulness departs. Certain venous
signs are of special importance, thus jugular pulsation is
regarded as pathognomonic of tricuspid regurgitation. In
every systole some blood passes backwards ere the auriculo-
ventricular valves are closed by the backward current of
blood ; but as long as the valve is competent this is (mly to
a small extent, but when the tricuspid becomes incompetent,
it is a very different matter. The veins then are no longer
properly emptied by the failure in their pump, the lungs are
congested from defective vis a tergo (asthenic congestion),
and the ventricle itself, enlarged and thickened from the
obstruction to the blood flow, except in the rare case of
primary tricuspid disease, is contracting powerfully but
inefficiently from this failure in its valve. The veins, alread}''
goiged from this imperfection in their pump, are now sub-
jected to the full force of the ventricular contractions, which
are only somewhat modified by the more or less imperfect
valve; this is a force which veins were never made to be
subjected to, and they speedily yield and become dilated,
their valves become incompetent, and each right ventricular
systole can be seen in the jugular veins. Considerable venous
engorgement and some dilatation even may have preceded
the tricuspid failure, but whether or not that failure soon
spoils the venous valves and renders them incompetent;
jugular pulsation ever indicates that the venous valves are

MODE OF EXAMINING THE HEART. 31

incompetent, and they are rarely rendered temporarily in-
competent, even in very grave attacks of cardiac dyspnoea,
consequently experience tells us that when found incompe-
tent, tricuspid regurgitation is present. Tricuspid regurgita-
tion is also, according to all German authorities, accompanied
by rythmical pulsation in the liver, from regurgitation ad-
mitting of the impulse derived from the right ventricular
systole being communicated down the vena cava inferior into
the liver, whose veins are then engorged. This riickwu'kung
(back-working) from tricuspid insufficiency has been espe-
cially studied by them, and I have been unable to find any
corroboration of Mr. Wilkinson King's theory in their litera-
ture.*

Professor Laycock, of Edinburgh, has drawn attention to
to the precordial veins in chronic heart disease, and, in some
cases, they are certainly dilated, but in many, indeed most
cases, there is no precordial venous injection.

Veins often partake of general atheroma, and are full,
round, not collapsing, and, in a manner, rigid. This is not
only seen in the ordinary subcutaneous veins, but also in the
coronary veins, which are often full, tortuous, and somewhat
rigid, when the foramina Thebesii have been compressed by
distension of the right auricle.

All reference to the cardiograph and smygmograph is
purposely oraitted, for two reasons — 1st. Such reference
could only be confusing to the great body of practitioners,
who cannot and do not use these instruments ; and, 2nd. That
they cannot be regarded so much of diagnostic use generally,
but, as Traube says,t rather to help us to " new facts;" and
there exists no more competent authority, whose opinion is
based on knowledge of the instruments and not on a confi-
dent ignorance. In addition to these two reasons, some
doubt may be fairly entertained how far we yet know

* An American friend is "highly sarcastic about "the safety-valve action of
the tricuspid," saying that the imperfectness of a valve is the most extraordinary
claim on our admiration that he ever heard put forward. It is opposed to the
very purpose which valves serve.

t This was in answer to direct question put to him by the writer, when
watching him take tracings with his improved cardiograph, in the wards of la
Charite, Berlin.

32 THE HEART AND ITS DISEASES.

enough of either mstrument to warrant the introduction ol
the subject into a general treatise. No doubt tracings are
very indicative to those who understand them, and in time,
when, among other things, improvements have been made in
the instruments themselves, including some less fallacious
plan of applying the knob than by a spring which can be
screwed down with a varying force, we may hope to find in
these tracings an accurate delineation of the heart's impulse,
or of the arterial pulse. But it is to be feared that the
tactus eruditus, the trained finger, will then be held in unde-
served disregard, for this advance in diagnosis by instru-
ments is far from an unalloyed good.

There is great room for fear that all that power to take
in a broad view of a case, with all its points included and
fairly appraised, which was so conspicuous in the old school
of physicians, and on which they could often base such very
successful treatment, is being lost sight of too much now ;
and that an almost superstitious reverence for instruments of
precision is taking its place, leading to undue importance
attached to some points, which can be precisely ascertained,
and to a certain neglect of other points not to be so closely
ascertained, but of equal or even often of greater import-
ance ; and consequently a less equal general estimate of the
patient's condition and requirements, and of the means
whereby the condition may be relieved. This is conspicu-
ous in Germany, where, in spite of a thermometer to indicate
temperature, and ice as a direct means of abstracting heat, it
is leading to a helplessness and feebleness in therapeutics
which, as seen very markedly in the Vienna school, is con-
verting the physician from a healer of the sick, from being of
any avail to a patient, the great end of physicians I pre-
sume, into a mere scientific observer of morbid action. This
is practically having a pathologist, and not a physician, at
the bedside.

In addition to the usual means of examining the heart,
Flint proposes to add " vocal resonance." It may be most
proper to give his own words. " The boundaries of the
heart may often be as accurately defined by auscultating the
voice as by percussion, and, in conjunction Avitli the latter

MODE OF EXAMINING THE HEART. 33

method, the former may be resorted to in determining the
augmented space which the heart occupies in cases of en-
largement. In females often, owing to the size of the
manimse, the diminution or extinction of vocal resonance
is more available in determining the area of the superficial
region than dulness on percussion." — (" Diseases of the
Heart," p. 68, 2nd ed., 1870.) There is a practical shrewd-
ness in this which at once recommends itself to the reader.

D

34 THE HEART AND ITS DISEASES.

CHAPTER III.*

Objective Symptoms — Palpitation — Irregularity — Inter-
MiTTENCY — Causes — Diagnostic Value — Prognostic
Value.

In perfect health the heart's function is performed without
consciousness and without evidence of its existence, except
after violent effort. Consequently when we find objective
symptoms of its existence and its functional labours, we do not
regard them as evidences of health, but as the witnesses of
disorder and disease. The first of these objective symptoms
is palpitation, a symptom common enough both in diseased
and in healthy hearts. Palpitation may indicate disorder ;
it may point to disease. Consequently much confusion
has existed, and even yet exists, as to its interpretation.
When hypertrophy of the heart was regarded as a disease
per se, and as a spontaneous increase in bulk on the heart's
part, till it became dangerous from its strength, we cannot
be surprised that palpitation was regarded as over-action of
the heart. How such over-action is possible in a hollow
muscle without complete closure and obliteration of the
cavities, terminating in death, if at all sustained, it is difii-
cult to imagine. As, however, hypertrophy is found to be
nearly absolutely in every case, and possibly yet may be
found in every case, to be a compensating growth to enable
the heart to fulfil its functions efficiently, so is palpitation
found to be an evidence of laboriousness.

Palpitation is quite unlike the steady blow of pure hy})er-
trophy, rythmical and creating no consciousness; it is an
unpleasant sensation, the sensation truly of heart taxation.
It is brought out readily by a little exertion in the dilated
heart, a final argument against its being over-action, for that

* This Chapter is founded on a series of papers contributed by the writer to
the Lancet.

OBJECTIVE SYMPTOMS. 35

would be just the time when over-action of the heart would
be most perfectly neutralized by the effort. A slight effort
in a dilated heart produces what much more violent exertion
only evokes in a healthy heart. Can it then be regarded as
evidence of weakness or of power ? It must be one or the
other ! Hope long ago pointed out that palpitation in its
maximum intensity could be found in a dilated right ven-
tricle at the very time when a patient was dying of cardiac
asthma, along with every other indication of failure of power.
Since then further observation has corroborated its connec-
tion with inability. " This sensation is rather the result of
the laborious contractions of an unhypertrophied organ,"
says Niemeyer. And the same authority states it is found
in dilatation before hypertrophy is added, and returns when
that hypertrophy is undergoing degeneration. It is the
associate of the want of power, not the concomitant of
excess of it. That it is found even in hypertrophy can-
not be questioned, but it demonstrates that that hyper-
trophy is insufficient, and is most effectually allayed by
agents like digitalis and belladonna, which incite the heart
into more perfect contraction instead of paralysing it. It is
found along with other evidences of cardiac failure, and the
pulse of palpitation bears no resemblance to the incom-
pressible pulse of true hypertrophy. The apparently violent
efforts of the heart have no effect upon the radial pulse as
part of the arterial system, a sufficient test of the presence
or absence of ventricular power. But if the evidence against
its being over-action in the diseased heart is complete, how,
the reader may fairly ask, do we find it in a perfectly healthy
heart ?

This perfectly legitimate question can be answered. The
centre of the circulation is muscular, and so is the peripheral
distribution of the arterial system. This last may be acted
upon and so affect the heart. Cyon. von Bezold, Ludwig,
and Rutherford have found that the heart beats may be
increased when every nerve communication of the heart
itself has been severed. By irritating the medulla when
the accelerator nerve was unsevered spasm of the arterioles
was called out, and with it excited action of the heart.

D 2

86 THE HEART AND ITS DISEASES.

WTiat, tlien, do we find, in fact, in the nervous palpitation of
the sound heart ?

Take a case of hysteria. We find violent palpitation, a
small cordy pulse, cold extremities, and, on the cessation
of the attack, a profuse flow of straw-coloured urine. We
have, then, disturbance of the vaso motor nerves, cold ex-
tremities from arteriole spasm, profuse diuresis, the result of
increased arterial tension, and palpitation, the evidcDce of
cardiac taxation, in the face of the opposition offered by the
spasmodic closure of the arterioles. So in Bright's disease,
where Prof Geo. Johnson has shown that spasm of the
arterioles is the exciting cause of hypertrophy of the left
ventricle, and that that arteriole spasm is caused by the
presence of urine excreta in the blood, so on an exacerba-
tion in Bright's disease, we have those cold extremities,
palpitation, profuse diuresis of pale urine in an exactly
similar manner. (See Chapter XIII.)

Palpitation, then, even in the sound heart is evidence of
taxation of the heart's powers, and this taken along with its
presence in cardiac dilatation, and its ready production then
by slight effort, will justfy our regarding it as evidence of
lack of power, and as such it will be regarded as we go
along; and whenever palpitation is mentioned, such is its
interpretation.

Palpitation is the first of the three witnesses of cardiac
inability, and as a temporary condition, is often found asso-
ciated along with the more serious manifestations of cardiac
failure. Next comes irregularity, and lastly, intermittency.
By irregularity is meant here irregularity in time, in rhythm,
not irregularity in volume, that is, pathognomonic of mitral
regurgitation ; though some irregularity in volume is appa-
rent in the more or less imperfect contractions of rythmical
irregularity. Irregularity is ventricular hesitation, a halting
of the ventricular contraction, which can be explained by
a small digression. The sensation of distension by the
cardiac ganglia provokes contraction, under the control of
the inhibitory fibres of the vagus. This control exercised by
the fibres of the vagus secures uniform contraction, and irri-
tation of the vagus can arrest for lengthened periods the

OBJECTIVE SYMPTOMS. 37

ventricular systole. But while there is a balance of power
normally betwixt the sensation of distension and the excita-
bility of the cardiac ganglia, controlled by the vagus fibres,
which may be disturbed, and thus irregularity result ; there
is also a balance of power between the blood to be driven,
and the power to drive it. As a matter of fact, irregularity
is most commonly associated with this last ; is certainly so
associated, w^e may fairly assume, when the other evidences
of cardiac inability are present. It may be associated with
exhaustion of the sympathetic system of nerves and dimi-
nished excitability of the cardiac ganglia. It is an arrest of
the ventricular systole, an arrest in the contraction of the
libres, a change of rythm. A prolonged impression on the
cardiac ganglia is necessary to excite contraction in the face
of the vis inertias of the blood column to be overcome, and
the restraining action of the vagus. When that contraction
is excited, it is short, sharp, and distinct. It is as if the con-
traction, instead of proceeding from one set of fibres to
another, from 1 to 2, 2 to 3, and so on from 6 to 7, the normal
number of layers of, fibres in the heart wall, had halted dur-
ing the time of the contraction of the fibres first in action,
and then a more than ordinarily synchronous contraction
had followed. Irregularity is here used as arrest during a
portion of the systole ; more prolonged arrest, as during a
whole systole, or more, is intermittency. Irregularity then
is arrested systole, and when occurring, as is mostly the
case, along with other evidences of cardiac failure, and more
especially when it is elicited easily by exertion, is an evidence
of muscular inability of a serious character, and is a more
grave admission of debility than palpitation. When auscul-
tating an irregular heart, we find at shorter or longer
intervals a pause. This B. W. Richardson thus describes :
" It is like a smith who, striking at the forge a number of
strokes in rythmical succession until tired, changes the
action for a moment to give a more deliberate and determi-
nate blow, and then rings on again in regular time." The
heart beats away pretty rythmically, and suddenly comes
this pause, with an indescribable sort of roll over, and on
again. The sensation to the auscultator is peculiar and un-

38 THE HEART AND ITS DISEASES.

mistakeable, and especially if auscultating without a stetho-
scope. It has always struck the writer as most resembling
tlie " change " of a horse's feet when cantering ; a momen-
tary pause, during which the other foot is put first, and then
on again. Whether the contraction of the v^entricle at this
pause commences from a new set of fibres or not, we will
probably never knoAV, but from the analogy to the relief
afforded to the smith by the change, and probably so to the
horse, we may deem it probable at least. The ventricle cer-
tainly halts, and this more too when the patient is exerting
himself or in excitement, than when at rest. When Senior
Resident Medical Officer of Leeds Dispensary, the writer
frequently noticed an irregularity in the pulse if felt when
first the patient entered the room, which was either not at
all, or in a much less degree, perceptible after a short conver-
sation. When any doubt may exist as to the causation of
the irregularity, as to whether it is a disturbance of balance
betwixt the vagus and the cardiac ganglia, or a disturbance
of balance betwixt the opposition ofi*ered in the blood to be
driven, and the muscular power to drive it, the question
admits of a ready solution. Let the patient make an effort :
over the disturbance of nerve balance this has no action ;
but in increasing the necessity for effort in the heart walls,
it has a very perceptible effect in increasing the amount of
irregularity ; when that irregularity is a disturbance of
balance betwixt the blood to be driven and the muscular
power to drive it. Frequently this pause is preceded by
three or four rapid feeble contractions, then the pause, and
rythmical contractions for a time, then the rapid strokes and
the pause. This condition is never found but in serious
dilatation, and is an indication of a very grave character; it
is often well communicated to the radifcal artery, and more
so if the arteries are themselves atheromatous ; in this
permanent condition, palpitation is readily induced by slight
effort.

Last and most serious admission of failure is intermittency,
i.e,, arrest of ventricular contraction during one or more
systolic periods. This prolonged halt in the heart's action
has been the subject of much investigation. Since the days

OBJECTIVE SYMPTOMS. 39

when the brothers Weber first excited it by irritation of the
vagus down to the most recent investigations of Rutherford
and Richardson, it has been the subject of attentive observa-
tion. As to its immediate causation, it has long been re-
garded as arrest of the ventricle until a second auricular
contraction produced sufficient distension to provoke con-
traction. Of the truth of this, the writer got proof in opening
the chest walls of two rats. This was not very skilfully
done, and the pulmonary collapse soon finished the rats ;
but as the rats died and the ventricle intermitted, it could
be distinctly seen that the ventricle waited till a second
auricular contraction excited ventricular contraction. More-
over, shortly it became manifest that even the second
auricular contraction was insufficient to excite contraction,
and the ventricle halted until a third auricular contraction
excited ventricular activity, and then the auricular contrac-
tion passed swiftly on into ventricular contraction. That
intermittency of the heart is arrest of the ventricular contrac-
tion over one or two auricular contractions may be fairly
asserted. It may further be presumed that the increased
distension of the ventricular chambers by the extra amount
of blood in them from these several auricular contractions,
was necessary to excite contraction in the ventricle. In
practice then, when we find distinct intermittency, it signifies
prolonged ventricular arrest from ventricular inability. In
auscultating a heart with fatty degeneration, who, with
much experience, has not waited for that lagging ventricle
in more than one instance, until a fear has arisen that its
arrest is going to be final ?

And when found along with other evidences of heart
failure, it is a sign of the most serious character : that long
ventricular halt is of grave import indeed, and when found
along with a diminished first sound, tortuous arteries, panting
respiration, and an arcus senilis with a cloudy cornea, is
significant enough. It is pathognomonic that the hyper-
trophy that once existed is going, is indeed far gone, never
to return.

We may alleviate the condition somewhat, but more is
impossible. We find, too, that such a patient is simply un-

40 THE HEART AND ITS DISEASES.

equal to the effort which excites palpitation, as in a heart
less structurally diseased. Though its irregularity of rythm
may be increased by slight effort, that heart is not equal to
palpitation : palpitation is an effort beyond it. Intermittency
is, however, not always so associated, and the two most
marked cases in the writer's experience, were both connected
with aortic obstruction. In these cases the intermittency
lasted over no less a period of time than four systoles. The
sensations of the patients during this period of ventricular
arrest were horrible. The terror excited was visible in their
countenances, and quite in accord with Romberg's account of
the patient's case given below. The arrest of the ventricular
systole before the obstruction offered by the narrowed aortic
orifice was pronounced, and enlightens us as to the tendency
in aortic obstruction to sudden death. If that halting
ventricle becomes structurally unsound, its halt will soon be
a permanent one.

Intermittency may then be an evidence of structural de-
generation ; it may also be present with good hypertrophy
even before a very decided obstacle to the flow of blood. It
may further be a result of irritation of the vagus, of which a
good case is related by Romberg (" Diseases of the Nervous
System "), which occurred in Vienna, This heart stood still
over a period of six normal beats, at intervals, its rythm
being good at other times. A diagnosis was made by Heine
and Skoda, that it Avas due to tumour of the vagus, and
when that heart finally stood still, Rokitansky found a tumour
like a cherry involving the vagus. The patient's sensations
during that halt were indescribably horrible, and a sense of
impending dissolution was overwhelming. That this is a rare
form of causation of intermittency may be at once taken for
granted. Arrest of the heart's action through the vagus by
a determined effort of will is not unknown ; but it is regarded
. as a hazardous experiment.

Finally, intermittency may be purely nervous ; may be a
disturbance of nerve balance, and that only. For an able
investigation of tliis subject we are indebted to the philoso-
phic mind of B. W. Richardson, who has paid great attention
to this intricate subject. That Dr. Richardson may have had

OBJECTIVE SYMPTOMS. 41

occasion to modify his views is merely proof of his earnest
wish to arrive at correct conclusions. And though I, in
common with the majority of tlie profession, cannot entirely
agree with him in his conclusions as to its divorce from all
organic diseases of the heart walls, still a debt of gratitude is
due to him for the able and persevering manner in which he
has demonstrated that this most serious symptom is not only
not invariably associated with grave disease, either in the
heart or elsewhere, but that it is often a mere nervous abnor-
mality of no pathological import.

It is well that this fact be known and recognised. On
mere intermittency of the heart alone, no practitioner is
justified in giving an opinion as to the existence of heart
disease. The suffering and misery entailed by hasty medical
opinions as to the existence of heart disease of a grave
character, and its proneness to sudden death, is some-
thing fearful to contemplate. I know well a hale north-
country yeoman, of unusually fine physique, whose peace of
mind, years ago, was ruined by a rash medical opinion,
formed most unjustifiably, and so strong was the impression
then made, that no amount of assurance of his health can free
him from terrible bondage of this idea.

Dr. Richardson has demonstrated how intermittency may
depend upon disease within the encephalon, and when so
associated regards it as a symptom of the worst omen. He,
further, has collected a most instructive and interesting series
of cases where persistent intermittency is the result of shock,
of anxiety, as in shipwreck, of grief, &c., in fact of a whole
series of psychical troubles, and where this intermittency is
quite unconnected with physical disease; and, finally, has
recorded cases where, after years of intermittency, no morbid
change could be detected, on post mortem examination, to
account for this symptom. Hence he has located inter-
mittency in the double nervous system of the heart. This
valuable work should put us on our guard against the im-
pression that intermittency is necessarily connected with
grave disease of the heart, still it is equally the fact that in
the large majority of instances it is so connected ; and as to

42 THE HEART AND ITS DISEASES.

whether it is so associated, or not, in each case must be
determined from consideration of the corollaries.

Finally we have irregularity and intermittency, the
common pro-dromata of death. We all form our opinion, in
many cases, of how long it will probably take for the sands
of life to run out, from the character of the pulse. When
the pulse becomes irregular, and then intermits, we know
the end is not far distant. So in all serious acute disease
this condition of pulse is regarded with great anxiety, and
not without reason. As regards the nature of the intermit-
tency we iind that in many instances, and in all acute specific
disease, and disease of the respiratory organs, the intermit-
tency in the radial pulse is significant of the condition of the
right ventricle. Enlightened by the lessons of the dead-
house, by the fact that commonly enough the left ventricle
is fau'ly contracted, while the right heart is gorged with
blood and distended, we come to learn that this condition of
pulse is significant of the condition of the right side, and not
of the left side of the heart. The right ventricle is struggling
away betwixt the difficulties of opposition ofiered to the flow
of blood in front, of over-distension from the gorged veins
behind, and with the numbing, paralysing effect of the
venous blood within it, highly charged with carbonic acid,
while the left ventricle is labouring under no difficulty in the
propulsion of its contents. But many of the fibres of the
heart are common to both ventricles, and consequently the
left ventricle keeps time with the nght, and can only trans-
mit the limited amount of blood coming into it from the
pulmonary circulation and the right heart. That this is so is
undeniable, but another proof of this can be found by aus-
cultation. The halt of the right ventricle is often pronounced
on auscultation before the hesitation in the radial pulse is
equally marked. How far inteiTaittency and irregularity in
the heart, and consequently in the arteries, is connected with
right side failure in some cases, and with left side trouble in
others, it is difficult to say. The subject needs investigation.
In many cases, where the heart afi*ection lies solely in the
right ventricle, as in cardiac asthma, the result of distension

OBJECTIVE SYMPTOMS. 43

of the right ventricle, not uncommon in persons who have
been subjected to prolonged trials of their "wind," as divers,
gymnasts, runners,* where the right side of the heart is
subjected to sustained strain, the irregularity and intermit-
tency are obviously connected with the right heart, and are
much more distinct to auscultation than to the finger on the
radial pulse.

The question of the connection and causation of these
objective symptoms with nervous affections of the heart, as
in Grave's disease, &c., will be considered in Chapter XII.

But their general significance and value in diagnosis and
prognosis are as given above, and in such sense and meaning
will they be used as we consider each form of cardiac failure,
and a remembrance of this will spare the reader much con-
fusion, which might otherwise arise, and spare much reitera-
tion, which would otherwise be called for. In the same
spuit must the contents of the next chapter be received and
remembered, for though it may be possible in one chapter to
review the difierent consequences of arrested circulation on
the different organs of the body, and the different subjective
symptoms of heart disease which arise therefrom, it would
be well nigh impossible to repeat each in every form of
lesion, or even to indicate which most commonly arise. But
when arrayed together the reader will not only better com-
prehend each, but will have a better conception of their
relative importance, and of their relation to each other.
Consequently it may not be altogether absurd to review the
general consequences of heart disease before considering the
diseases themselves.

* See Dr. ClifPord AUbutt " On Distrain of the Heart." 1872.

44 THE HEART AND ITS DISEASES.

n

CHAPTER IV.

The Consequences of Obstructed Circulation, or the
SuBJECTR^ Symptoms of Heart Disease — Pulmonary
Circulation — Cerebral Circulation — Liver — Spleen
— Stomach and Intestinal Canal — Kidneys— Genito-
urinary System — Serous Membranes — Anasarca —
Inability to Sleep in the Recumbent Posture—
Symptom of Cheyne — Conclusions.

The various pathological conditions arising from obstructed
circulation, and the symptoms to which they give rise, may
advantageously be regard ed together, and when so collected
will more lucidly explain the various symptoms, concomitant
and intercurrent affections, which arise during the progress
of most forms of heart disease, in a greater or less degree.
The importance of placing these altogether is recognised
mostly by German writers, who lay great stress upon the
" ruckwirkung," or "back-working." Affections of the aortic
valves are not accompanied by these con^sequences until the
mitral valve becomes affected, whether by extension of the
endocardial mischief, or by the valve becoming incompetent
by atrophy of the musculi papillaries, or enlargement of the
cavity of the left ventricle. Thus in the earlier stages of
aortic insufficiency the greatest danger is the risk of rupture
of the cerebral arteries and the formation of true apoplexy.
But when the mitral valve has become implicated, whether
secondarily to aortic disease or originally, then ensue a series
of changes and symptoms consequent on the arrest in the
circulation. The pulmonary vessels become distended, the
right ventricle becomes dilated and hypertrophied, the arrest
in the circulation sooner or later extends backwards, and in
this order we propose to consider them. First, then, comes
dilatation of the pulmonary artery and its branches, thicken-
ing of their coats, and ultimately a distinctly atheromatous

SUBJECTIVE SYMPTOMS. 45

degeneration of them, and even fatty degeneration of these
altered vessels.

In consequence of this increased bulk of blood constantly
in the pulmonic circulation, we have very commonly increase
of the connective tissue, or hypertrophy of the lungs passing
on to atrophy, deposit of pigment in excess, &c. But more
surely as time rolls on we have emphysema. The violent
efforts at respiration entailed by the increase of bulk of blood
in the thorax, and consequently diminished space for the
lungs to play in, thus lead to rupture of the air vesicles,
favoured by the altered condition of the lungs themselves,
especially in the older and more advanced conditions of
degeneration. There is congestion of the bronchial mucous
membrane, and effusion of serum and mucous flow ; this
further adds to the difficulties of respiration. Frequently the
pressure on the pulmonic circulation becomes so great,
especially betwixt a strong right ventricle and a ^' button-
hole " mitral, that we have rupture of the coats of the vessels
and. haemoptysis. This rupture may take place into the
structure of the lung itself and cause true pulmonary apo-
plexy, or the Infarctus Laennecii, the formation of black,
round clots of blood the size of a bagatelle-ball. In more
advanced conditions we have pluritic effusion. These patho-
logical conditions have as symptoms — impeded respiration,
dyspnoea, easily excited by exertion, cough, increased flow
of bronchial mucous, hsemoptysis^, and the marked tendency
to undergo transient exacerbations of exaggeration of all
the symptoms, constituting those terrible attacks of cardiac
asthma, which add so seriously to the patient's sufterings.

When the effect is felt backwards from the tricuspid valve
the venae cavse become distended. The venae cavse are pro-
tected by valves, and thus regurgitation is arrested normally,
but in time the distension of the veins renders these valves
incompetent. Long, however, before this valvular incom-
petence has become apparent objectively, there has been a
considerable venous congestion, and in this the cerebral cir-
culation takes part. The brain is in the condition of constant
excess of venous blood, while it too frequently suffers from a
want of sufficient supply of arterial blood. This leads to

46 THE HEART AND ITS DISEASES.

excess of connective tissue in the brain, so-called hyper-
trophy, passing on to atrophy, accompanied by eifusion of
serum into the ventricles, chronic hydrocephalus, increase in
the amount of cerebro-spinal fluid, &c. This venous stagna-
tion has also been regarded as a factor in the production of
arterial apoplexy, from the obstruction offered to the flow of
blood. Under these circumstances, then, we are not surprised
to find mental manifestations not uncommon in heart disease.
Most constantly and generally observed in all text books is
the frequency of horrible dreams. These torture the little
rest such sufferers often are allowed, and more so after a
heavy supper, and often precede the attack of cardiac asthma
with which the patient wakens. There are, too, constantly,
in a greater or less degree, a sensation of swimming in the
head, pain, dizziness, vertigo, singing in the ears, ringing,
&c., and sensations of unsteadiness. There are, too, the
accompanying conditions of mental irritability, want of fixity
of purpose, instability, caprice, petulance, and tendency to
eiToneous reasoning and calculations. Thus the strongest
and clearest headed man may become childish, irresolute,
timorous, and easily perplexed, or irritable and capricious.
These mental alterations add much to the difiiculty of treat-
ment, and have not been sufficiently recognised, and many a
little unpleasantness, as well as more serious ruptures be-
twixt patient and medical man might be avoided, if a better
general knowledge on the subject existed.

There are often, too, changes in the eye, which cannot be
further alluded to here, and variations of vision. While the
features are often vascular, congested, with blue lips, &c.,
and, in the attacks of asthma, even cyanotic, there is often
numbness in the hands, and pain down the left arm, and
other nervous symptoms, whose proper symptomic value
has not yet been appraised, but form a famous field for some
energetic worker.

So, too, there are disorders connected with the lower
vena cava, and especially the valveless portal circulation.
This condition is spoken of generally as abdominal
plethora (plethora abdominalis). The various organs thus
suffering from venous congestion become altered in structure

SUBJECTIVE SYMPTOMS. 47

and in-egular in function. Thus in the liver we find increased
connective tissue and cirrhosis; during the progress of this
process we naturally find disturbances or liver symptoms,
and this, too, in the upper classes, whose means lead natu-
rally enough to the pleasures of the table ; not that any
positive indulgence may exist, but the weakened organ is
less equal to the performance of its function. There is a
coQdition of serous effusion into the bile, termed by Oppolzer
" albumicholic," and he further states that in this condition
there is congestion of the mucous lining of the bile duct, the
formation of jaundice, &c., thereby, and that this, too, is
commonly produced by a simple cold. In many instances
the liver undergoes venous engorgement, and is much in-
creased in bulk. Altogether the liver is very commonly an
organ whose disordered function is one of the most common
signals of those changes of structure which follow in the
wake of heart disease, and may even constitute the chief
symptoms.

The spleen participates in this abdominal plethora, and
may almost always be found enlarged ; as we do not yet
know of any subjective symptoms of spleen affections, no
functional manifestions can be described of its engorgement.

But is is very different with the stomach and intestinal
canal. Most certainly and surely do we have not only
changes in consequence of this venous engorgement, but the
manifestations of disturbance have long been known and
marked. The symptoms of stomach and bowel derangement
in connection with heart disease are to be found in every
text-book. The first and most constant affection is catarrh
of the stomach, not as an affection per se, but rather part of
the general venous stagnation and its effect on mucous
membranes. This increase in the amount of mucous is a
frequent source of trouble. It commonly enough induces
indigestion by covering the food taken by a coat of mucus,
which renders digestion impossible ; so attacks of indiges-
tion are usual and easily provoked, in spite of the care of the
patient and the physician. In this condition of the mucous
membrane, the disengagement of gas is troublesome. The
amount of eructation often seen in elderly subjects with

48 THE HEART AND ITS DISEASES.

chronic heart disease is surprising, and the appearance even
ludicrous. It is no joke, however, to the patient, and often
creates both suffering and alarm, and by pressure on the
diaphragm and right heart very unpleasant palpitation is
induced. There are, too, in this altered mucous membrane
sensations and cravings after highly-spiced and tasty food,
often very unsuited to the digestive powers, and these,
along with the cerebral symptoms often lead to disagree-
ments of opinion. There is one symptom in connection with
this condition of gastric catarrh of great importance, and
mdeed Dr. King Chambers regards it as pathognomonic of
heart disease, and that is the " sensation of fulness " ever ex-
perienced. Even though the patient is hungry, and feels so,
still that sensation of being already " too fall " is there. This
is one of the most common concomitant symptoms of heart
disease.

The intestinal canal partakes of this general congestion,
and furnishes, along with it, disorders. These may be
generally divided into two divisions ; one, irregularity of the
bowels, constipation and its accompanying symptoms from
inefficiency in the muscular fibre of the intestinal canal.
This is, of course, more common in the large lower bowel
and in the rectum, and then indicates enemata and aperients
or soap suppositories (Trousseau).

The other division belongs to congestion of the mucous
membrane, and its results. Thus, not uncommonly, the
patient has passive diarrhoea, often furnishing great relief,
and only to be treated when becoming unquestionably exces-
sive. Alternations of constipation and purging frequently
occur. This condition of mucous membrane is continued to
the formation of piles. Bleeding piles or haemorrhoids are
very common in the sufferers from chronic heart disease, and
their bleeding is not uncommonly accompanied by sensations
of relief; and not unfrequently Avhen no bleeding has oc-
curred for some time, a flow of blood from another organ
may occur, as ligemoptysis for instance.

The effects upon the kidneys are also direct and unmis-
takeable, but this subject is not so simple, and needs some
little consideration. There is a great relationship betwixt

SUBJECTIVE SYMPTOMS. 49

kidney and heart disease, as was observed by Dr. Bright.
But while he and most other physicians have regarded the
kidney disease as primary, and the heart disease as secon-
dary, some have always maintained that the kidney disease
is always and only the result of previously existing heart
disease. The connection of heart disease with kidney disease,
as its cause, will be fully discussed in a following chapter
(Chapter XIII), and here we have merely to do with kidney
disease as the consequence of venous congestion due to pre-
existing heart disease. Often, indeed, are seen the recent
changes in the kidney engrafted on old standing disease.
Consequently difficulties have been made about this subject
which would long ago have been cleared up, had precon-
ceived opinions not manipulated the evidence. Whether old
kidney disease have existed or not, is nothing to the question
of the production of recent kidney mischief. When, then,
this venous stagnation has led to the usual result, the pro-
duction of connective tissue in excess, it may be limited to
the part of the kidneys remaining sound, or if not altered by
previous disease, all the kidney ; there is usually albuminuria.
When a person without old kidney disease is beginning to
suffer from this venous congestion, there are, then, more or
less albuminuria^ diminished flow of urine, indicating less
arterial pressure on the glomerali ; the urine is dark-coloured,
scanty, and of high specific gravity, with exudation casts or
fibrin-cylinders. But where old kidney disease has existed
with affection of the left ventricle, a totally opposite series
of urine symptoms may have existed. There may have been
free flow of pale-coloured urine especially at night, albumen
scanty and altogether absent, frequently for lengthened
periods ; the specific gravity low, and the tube casts granu-
lar, small, and contracted. But when sooner or later, if not
carried off in the mean time by inter-current disease, the
symptoms change, on the failure of compensating power in
the heart itself, we have venous stagnation and its conse-
quences, and the symptoms peculiar to that condition. This
antagonism betwixt the symptoms of early kidney disease,
and the opposite condition when venous stagnation has set
in, has led to much confusion ; but when the changes are

50 THE HEART AND ITS DISEASES.

correctly explained, and for this we must chiefly thank the
Germans, there does not exist much real difficulty; the
difficulties arose from an imperfect pathology, and more
exact observation has removed them. Of course, it is possible
to have even old standing kidney disease, the result of old
standing heart disease, as we may have old standing secon-
dary disease in other viscera ; and further, all kidney com-
plication must necessarily add quickly to the heart's troubles.
As the primary affection, so its consequences, when it runs
its course quickly the changes in the parenchymatous
organs are recent; when its course is chronic so is the
character of the changes of structure which follow in its
wake. (For further information on the connection of heart
and kidney disease, see Chapter XIII.)

Much less discussed, because not so involved, are the
diseases of the genito-urinary system. These of course
make themselves most apparent in the female sex. This
venous stagnation leads to the usual consequences in mucous
membranes, and so we have leucorrhoea a prominent symp-
tom. This is natural enough and easy to comprehend, nor
is it difficult to understand that those natural periodical
discharges of blood from the female genitals are increased in
quantity, and even in frequency, by venous congestion of
the uterine vessels. Thus menorrhagia is common during
the period of a woman's life when she has these discharges,
while flows of blood at other times will occur (metorrhagia),
and even persist after the cessation of the menstrual flow.
Oppolzer was inclined to think that profuse menses often
accompanied the arterial fulness of aortic insufficiency, and
regarded it as a symptom of some value in that form of
valvular disease.

In addition to these, Von Dusch is inclined to regard
metritis itself as a result of venous congestion, and it would
only be in accordance with the general law of the connec-
tion of increase of connective tissue (interstitial inflamma-
tion) with venous congestion if this were so. That we must
regard the more peculiarly female diseases as the not un-
common consequence of pre-existing heart disease, is in-
evitable. In the male sex this will lead to vesical catarrli,

SUBJECTIVE SYMPTOMS. 51

prostatic congestion, especially likely to occur in connection
with the absence of haemorrhoids in the distribution of the
blood through the haemorrhoidal vessels ; and Oppolzer even
goes so far as to attribute hydrocele to congestion of the
pampinniform plexus.

This obstruction to the circulation is also felt in the
tissues, especially the areolar tissue under the skin, and may
show itself at varying intervals, according to the patient's
condition. This condition when general is termed anasarca,
when limited oedema, but is still popularly termed dropsy
(hydrops), and by the laity regarded with great alarm. Nor
is this without reason, for this condition is rarelv absent from
the later stages, and as non-professional people do not inves-
tigate processes, but merely mark relationships, its almost
invariable presence before death naturally enough inclines
them to regard it as an almost certainly fatal omen. It must
not, however, be so regarded by us ; still its significance is
unmistakeable, and it shows that there is an accumulation of
water in the blood, probably from the feeble circulation not
bringing the blood sufficiently in contact with the excretory
organs. It has also been surmised that the retained urine
salts in the blood have a tendency to make the fluid portion
escape more easily out of the vessels. There is no direct
proof for this except that renal dropsy has a more marked
tendency to show itself generally, while genuine cardiac
dropsy is found in the most dependent parts, and therefore
first in the feet and legs. So in general debility and feeble
circulation the dropsy, often present, is in the lower extre-
mities.

When there is *' puffing under the eyelids," from oedema,
there is at once ground for suspecting renal complication
with the heart disease. So, too, in the most advanced con-
ditions, when the kidneys almost invariably become afiected,
there is a tendency in the dropsy to become more general.
At first there is a slight oedema over the foot and round the
ankle, and a slight " pitting on pressure," ^.^., the impression
made by the finger persists for some little time, like a pit in
dough or putty. This may soon vanish, especially by appro-
priate means, but sooner or later, may be years under fortu-

E 2

52 THE HEART AND ITS DISEASES.

nate circumstances, it returns, each time more persistent, and
each time more intractable. In more advanced conditions it
can only be kept at bay for some limited periods, and soon
establishes itself permanently. I purposely use these expres-
sions, as whatever the reader may think when treating a
patient with heart disease, the nurses, the friends, and the
patient will all form their prognosis from the attitude of the
dropsy.

Sometimes, however, di'opsy will come on quite suddenly,
and when this occurs great relief is often felt, and the other
symptoms are naturally relieved by this drain of bulk of
fluid away from the gorged veins and right heart. When
dropsy does come on quickly, and generally, there is a better
prospect of its remaining away for a lengthened period than
when it makes its appearance gradually and insidiously.
This is an empirical fact, which must not be forgotten in
making a prognosis. When the gradually increasing dropsy
has been successfully combated for a time by appropriate
remedies, and returns again while the patient is under treat-
ment, it is an omen of the worst import. As dropsy pro-
ceeds upwards, it involves the knees, thighs, and scrotum ;
indeed wherever there is areolar tissue and lax skin, it will
locate itself in force. Often a temporary improvement in
the conditions of the limbs will be found,, but along with it
evidence of increased distress to the patient. Here there is
every reason to susj)ect temporary oedema of the lungs. An
increase in bulk again in the legs will often give relief The
dropsy will then settle itself over the back, shoulders, and
in the arms ; but by this time there is usually evidence of
effusion into all the serous sacs, peritoneum, pleura, peri-
cardium, and cerebi'al ventricles ; carbonic acid poisoning
and coma will show themselves, and soon the scene closes.
Occasionally oedema glottidis is the immediate cause of death,
but not frequently.

During this period of time the skin, stretched by the
effusion into the subcutaneous areolar tissue, is liable to certain
lesions. On points of pressure it is liable to take on that low
form of dermatitis, commonly called " erysipelas," an objec-
tionable expression, as confounding it with genuine erysipelas,

SUBJECTIVE SYMPTOMS. 53

a serious pyrexial disease. So commonly does this inflamma-
tion of the skin follow incisions, needle pricks, &c., for the
relief of dropsy, that the liability to it forms a strong objec-
tion to resort to these measures. The skin, too, is liable to
eczematous affections, and sometimes these self-established
drains are of great service ; at other times they merely add
to the patient's sufferings. When there is a combination of
heart and kidney disease, eczema is usually present for long
periods ; but how far the skin is itself affected by this venous
congestion at early periods, and what relationship there is
betmxt skin affections and obstructed circulation, is not yet
worked out. Hebra states that ulcers are ordinarily con-
nected with obstructed circulation, and I have seen very
obstinate ulceration in the legs of females with heart affec-
tions.

The serous membranes are not usually affected by ob-
structed circulation, except in the more advanced stages of
heart disease ; when they are established they add much to
the sufferings. When fairly established respiration is only
possible in a sitting posture, when the fluids fall away from
the lungs and heart by their own gravity.

But inability to breathe in the horizontal posture is not
only found in the more advanced stages, but may occur at
the earlier periods, especially during paroxysms of asthma
(cardiac). It seems often connected with pressure in the
diaphragm from the abdominal side of it, and thus pressure
on the right ventricle which lies on the thoracic face of it.
Thus increase in the contents of the stomach or transverse
colon tend to press the diaphragm against the right ven-
tricle, and it is in those conditions where the right ventricle
is especially involved that we find relief afforded by the
sitting posture. The contents of the abdomen then fall away
from the thorax by their own weight, and relief more or less
complete is afforded. This is not yet regarded as the abso-
lutely correct interpretation ; but it is more probable than any
of the older theories, and certainly must, at least, have some-
thing to do with it.

Finally, in the last stages of death from heart disease
with dropsy, we find the patient becomes subject to carbonic

54 THE HEART AND ITS DISEASES.

acid poisoning. The evidence of the accumulation of car-
bonic acid in the imperfectly depurated blood is drowsiness,
increasing gradually, though the patient can be roused to
answer questions by more or less importunity, but the eyes
soon close, and the patient dozes, with fading resph-ation, till
the necessity for breathing wakes the patient up with looks
and sensations of alarm, for that summons to waken and
breathe takes the form of a hideous dream. The di'owsy
patient feels the sensation to sleep so strongly, that even the
dread of those horrid dreams is unable to make him resist,
and in terror of the consequences he drops off once more
into his fitful sleep, again to waken in terror and alarm.
There is only one consolation for all this condition, and that
is, it is impossible for the human system to sustain it long :
that mtolerable infliction cannot long be borne.

In connection with this subject is the symptom of Cheyne,
quoted by Stokes. The respiration comes and goes in ebbs
and flows, gradually deepening into full respiration, then
fading away into one or two complete remissions of respiration.
It would seem that the exciting cause of respiration could
accumulate till a few full respirations can afl'ord complete
relief, then the respu-ation becomes shallower, till it is appa-
rently lost ; then the necessity for respkation excites deeper
breathing, and so this goes on in a rythmical ebb and flow.
Frequently about 15 respirations elapse betAvixt minimum
ebb and ebb, and betwixt maximum flow and floWw But
this, though very common, is not necessarily connected with
heart disease, still less with the special form of fatty degene-
ration; indeed the second good case in my experience occurred
in a patient who died of genuine apoplexy, and whose son,
in sitting by his father's bedside, having some knowledge of
medicine, found his attention largely absorbed by this phe-
nomenon, and made accurate observations on it.

But while the patient sufl"ering from heart disease is
liable to all these different affections, it must not be supposed
that he must necessarily have them all, or that there may
not be periods when he is almost free from all subjective
symptoms as long as quiet is maintained ; indeed, in some of
the milder cases of aoi'tic disease great bodily activity may

OBJECTIVE SYMPTOMS. 55

be possible without evil result. Niemeyer relates a case
where a huntsman in the Griefswalcl had considerable aortic
disease, compensated by hypertrophy, who performed all the
marches of the war of 1866 without suffering symptomatically.
In some forms of insidious fatty degeneration, indeed, sudden
death may carry off the patient before any subjective symp-
toms have shown themselves, and this, too, especially when
death results from effort. But in the great majority of cases
more or feAver of these symptoms will show themselves in a
more or less marked manner, and certainly before the end, if
the patient be not carried off by intercurrent disease. In-
tercurrent disease is always much more serious in a patient
who is already the victim of heart disease, and passing affec-
tions are more easily produced by slight causes than in those
in perfect health ; and, further, these must be more carefully
watched and treated.

We may sum up, then, in the four following con-
clusions : —

1. That when heart disease exists, with venous stagna-
tion, many structural changes in the viscera follow ; and that
these pathological changes are accompanied by manifesta-
tions of functional disorder.

2. Though all functional disturbance, &c., be not the
direct result of the heart disease, but have arisen from causes
so-called accidental, still these disturbances are more easily
produced where chronic heart disease exists than in those
who are perfectly sound.

3. That in chronic heart disease the margin betwixt
ordinary health and death is lessened; and, consequently,
that the limits within which health and ill health may safely
oscillate are diminished.

4. Under these circumstances many trivial disorders,
which in a healthy person may safely be left to take care of
themselves, must be promptly subjected to their appropriate
treatment.

56 THE HEART AND ITS DISEASES.

CHAPTER V.

Hypertrophy and Dilatation —Histological Changes —
Hypertrophy or Hyperplasia — Probable Mode of
Genesis — Causes or Conditions along with which
found — Obstruction — Distension under increase of
Pressure — Displacement— Temporary Conditions of
feebleness of Heart-walls — Niemeyer's Hypertro-.
PHY — Lipoma? Traube's three Divisions; Diagnosis
OF EACH— Inspection — Palpitation— Percussion — Aus-
cultation — Right Side Hypertrophy — Subjective
Symptoms — Prognosis of each Form — Treatment —
Question of Permanency — Is Hypertrophy ever De-
structive ?

This is perhaps the most important chapter in a work on
heart disease, and consequently must be dealt with at some
length. It is of the last importance in estimating the
prognosis of the great majority of cases. The subject is not
altogether free from difficulties, but they will disappear with
a little well applied attention, and the chapter is so arranged
as to put the different sections in their respective positions
to explain themselves, as far as the writer is capable of such
arrangement.

The first point is the question of what are the changes in
the heart fibre in hypertrophy. These have been stated to be
increase in length and breadth, hicrease in number of fibres,
or accumulation of fusiform involuntary fibres, not attain-
ing to the higher condition of striped fibres. This last was
largely held in the earlier days of heart pathology. There
is a condition somewhat similar to this, but it is that of false
hypertrophy. Here there is a development of connective
tissue betwixt the muscular bundles of the heart-wall ; but,
as Sir William Jenner has pointed out, there is no real hyper-
trophy, no increased power here, but really decrease of it,

HYPERTROPHY AND DILATATION.

57

Fia. IV.

Muscular Fibre of Heart
(from RindfleiscL) .

by the connective tissue impeding the action of the muscular
fibres themselves. In hypertrophy of the heart there is no
growth of tissue in any way different from normal heart fibre.
Then for a long period it was held that in hypertrophy of
the heart the separate fibres were increased in length and
breadth — true hypertrophy. This view
has been held and taught by Rokitansky
and Forster, but they have never been
able to demonstrate these changes
under the microscope. Then, lastly,
it has been stated and demonstrated
that the increase in bulk in the heart
is due to a true hyperplasia or develop-
ment of an increased number of fibres
in no way differing from the normal
fibres. This last view is adopted by
Dr. Rindfleisch, and he gives a plate of
the muscular fibre in this hyperplasia
of which this is a copy.

The colour of an hypertrophied heart is somewhat darker
and redder than a normal heart, firm in its consistency, so
long as it is true hypertrophy. The extent to which it
may proceed is practically unknown, but it may reach to the
size of a bullock's (the cor bovinum), and weigh 40 oz. and
more, the ordinary weight of the normal heart being in
women 8 oz., and in men 10 oz. We do not know if any
corresponding increase has gone on in the nerve supply of
the heart. A great deal on this head requires to be cleared
up, and in consequence of the difficulties attending the obser-
vations, it is not probable that much will be done for some
time.

As to the mode in which hypertrophy of the heart is
directly induced, it has been held that it was a spontaneous
growth to overcome obstruction, ahvays remembering that
for some years it was regarded as a disease pei" se, and as
such subjected to treatment with the idea of reducing it.
But soon it became apparent that in almost every case of
hypertrophy of the heart an obvious cause was visible, some
obstruction to the flow of blood, as aortic obstruction,

58 THE HEART AND ITS DISEASES.

atheroma of the aorta and loss of its elasticity^ &c. But, in
addition to those, the most marked hypertrophy is found
when the heart is exposed to distension under increased
pressure, as in aortic regurgitation, where the flaccid left
ventricle is distended by a stream of blood driven backwards
by the aortic recoil, as well as by the blood coming in from
the mitral valve. So too in mitral regurgitation we have
dilatation and hypertrophy of the left ventricle when no
obstruction is offered to the flow of blood into the aorta.
Here we have hypertrophy to resist excessive distension.

We find it, too, when the heart is labouring at a disad-
vantage as in displacement, or in complete pericardial ad-
hesion. It is also found to follow dilatation from temporary
disability of the heart, as after pericarditis and softening of
the heart walls by the inflammatory process. In fact, we
find it whenever the heart is placed at a disadvantage and is
likely to yield to the force of circumstances, and even after
yielding hypertrophy steps in and arrests the progress of the
dilatation. If we are to read the difficult subject by the light
of the recent experiments of Cyon, Ludwig, von Bezold, Brun-
ton, and still more even Rutherford, it would appear that a
sensation of distension, of disability, is received by the cardiac
ganglia, that that excites a vaso-inhibitory action and dilata-
tion of the vessels of the coronary circulation, and " a broad
and more rapid stream " of blood furnishes the material for
an increased tissue growth.* This is not certain, but it is
highly probable, and is quite in unison with our experience,
that hypertrophy more perfectly and quickly occurs in con-
ditions of good general vitality, less perfectly and with more
dilatation in less favourable systems, and not at all, remain-
ing simple dilatation, in systems of least resistive power.
This explanation of the origin of hypertrophy will be much
aided by our reviewing the causes, or, as some may prefer to
call them, the conditions which give give rise to it.

Causes. — These may be divided generically into A, Ob-
struction ; B, Displacement ; C, Distension under increased
pressure ; D, Dilatation from temporary causes of debihty in
the heart-walls themselves.

* See first chapter, section on Cardiac Innervation.

HYPERTROPHY AND DILATATION. 51)

A. Obstruction offered to the flow of blood of whatever
nature. When this occurs at all quickly, usually some dila-
tation takes place before the hypertrophy becomes developed ;
where it is slow and gradual in its progress, the hypertrophy
is often pure and uncombined with any visible dilatation.
We may conveniently sub-divide this division into its several
parts, which will aid in preventing confusion, which might
arise if the different sub-divisions were mixed up together.

1. We have, then, one of the most marked in obstruction
offered to the flow of blood from the left ventricle by stenosis
of the aortic orifice. This is usuallv from chronic endarteriitis
or atheroma, and is gradual and slow in its growth, and the
hypertrophy is usually pure.

2. Aortic aneurism is also a common cause of hypertrophy
of the left ventricle, from the obstruction which it offers to
the blood stream.

3. Pressure on the aorta by a tumour, or other cause,
which presses on the aortic tube and constitutes an obstruc-
tion.

4. Aortic atheroma is a common cause of hypertrophy of
the left ventricle. When the aorta is thus diseased it loses
to a large extent its elasticity, and instead of becoming
distended and then by its recoil, due to its own elasti-
city, promoting the flow of blood, it becomes a compara-
tively rigid tube, and presents a decided obstacle to the
flow of the blood. In other cases the atheroma may be in
patches, often annular, and thus by allowing the tube to be-
come distended in some parts and rigidly held of unchanged
calibre in others, a decided obstruction is offered. Hyper-
trophy of the heart sets in to overcome this, and for a time
does so often pretty effectually, but it is usually evan-
escent and wanting in permanancy. As to the connection of
this condition with Morbus Brightii, it is not gone into here,
because it will natui'ally belong to the chapter devoted to
the consideration of the relation of heart disease and kidney
disease to each other.

5. Hypertrophy of the heart is often, almost invariably,
found with more or less dilatation, in that curious disease,
exophthalmic goitre. Grave's disease, &c., which Trousseau

60 THE HEART AND ITS DISEASES.

describes as a neurosis of the sympathetic. Here we find
that there is reason to suppose the existence of varying con-
ditions of cahbre in the smaller vessels, in some parts contrac-
tion, and in others again dilatation, where there is also an
obstacle offered to the flow of blood through these tubes of
varying calibre. This last cause of impeded flow of blood is
not perhaps so certainly settled pathologically as the pre-
ceding divisions, which do not admit of doubt. The follow-
ing division is of great interest, but has only recently
attracted its due share of attention.

6. Excessive labour with the arms chiefly. This subject
has been more studied in relation to the causation of aortic
regui'gitation than with its effect upon the heart-walls them-
selves. More recently Dr. Myers, in the Alexandra Prize
Essay, and Dr. Clifford Allbutt, have drawn attention to pro-
longed strain on the heart itself. The subject is sufficiently
important as well as interesting to w^arrant our devoting
some especial attention to it. The prevalence of heart dis-
ease, and that too especially of one form of valvular disease
in men who follow particular occupations involving the use
of the arms, as in hammer-men (strikers), colliers, and others,
has been for some time observed. It is common, sadly com-
mon, throughout the great industrial regions of England. In
the majority of cases the sufferer is exposed to severe, ex-
treme exertion for a brief period, as in a hammerman during
the brief period of time that iron remains sufficiently hot to
be worked ; or in colliers in thin seams of coal, where the
collier is working in a constrained position, which from its
ii-ksomeness cannot long be maintained. Here we find that
while the muscles, all acting towards the trunk, tend to force
the venous blood mto the great venous centres, the muscles
often cross the arteries and impede the flow of arterial
blood; indeed Wardrop called this the musculo-cardiac
function. Not only so, but the fixed position which these
labourers occupy in their work, whether in a constrained
position or a fixed attitude, to enable blows to be delivered
with greater force and precision, by its muscular rigidity
opposes the flow of blood into the muscular system generally.
This obstruction leads to hypertrophy of the heart, often

HYPERTROPHY AND DILATATION. 61

combined witli some dilatation, and thus the left ventricle
constantly throws a large mass of blood under high pressure
into the aorta. In time this, added to the opposition offered
to the flow of blood in the arteries, produces such aortic dis-
tention and recoil as leads to chronic inflammatory changes
in the aortic valves and the establishment of aortic regurgi-
tation and its changes. But from experience among this
class the writer is perfectly satisfied that there is a condition
of hypertrophy, with more or less dilatation in the left
ventricle previous to the development of aortic disease.

Indeed, long before the establishment of aortic disease,
these patients will often present themselves for treatment
for palpitation, &c., the evidence of laborious action. But as
the heart 'hypertrophies to meet this demand these symptoms
pass away, and the hypertrophied, and probably dilated ven-
tricle, throws at each systole an abnormally large bulk of
blood into the arterial system. This, by producing increased
aortic distension, leads to increased recoil and forcible closing
of the aortic valves and disease of them. But in other cases
of severe labour, especially in young persons, a condition of
dilatation is induced, which often leaves them more or less
incapacitated or crippled for labour.

7. Obstruction to the flow of blood in the pulmonary
artery. This is a cause of hyperti'ophy in the right ven-
tricle, and may arise from congenital narrowing, from left
side disease, from pressure on the pulmonary artery by aortic
aneurism in other pressure, as a tumour, &c.

8. Diseases of the respiratory organs. Chronic diseases
of the respiratory organs commonly lead to enlargement of
the right ventricle from the obstruction they offer to the
flow of the pulmonic circulation. These diseases are chiefly
bronchitis, emphysema, cirrhosis of the lung, pleuritic effu-
sion, &c. These two causes, 7 and 8, affect the right side of
the heart alone and produce those symptoms peculiar to it
which will be found described in a later section of this
chapter.

B. The heart also hypertrophies when placed under cir-
cumstances where it can only labour at a disadvantage, as
when displaced, from whatever cause, or bound down by

62 THE HEART AND ITS DISEASES.

pericardial adhesions. When so incommoded, the heart can-
not so efficiently perform its function as when in perfect
freedom, and so hypertrophy is inaugurated. This is an
imjDortant section of the causes of hypertrophy, because here
we have neither obstruction offered to the flow of blood, nor
have we the heart filled under any excessive pressure, the
two most commonly recognised causes of hypertrophy. We
have the heart merely incommoded in its action by displace-
ment or adhesion, and hypertrophy comes in and enables it
to perform its function. Here evidently the disadvantage
under which the heart labours tends to its incomplete
emptying itself, and soon we would have dilatation, and then
the compensatory process of hypertrophy again balances
matters. The causes of displacement, and consequent hyper-
trophy, are the following : —

9. Pleuritic Effusion. — This is the most common of ail
causes of cardiac displacement. It is usually on the left side,
and when so occurring, the heart is displaced to the right
side, and the apex may in some cases be found beating under
the right nipple. In other cases it is on the right side, and
then the heart is forced more to the left of its normal posi-
tion, and is often tilted up at its apex. Under these ch'cum-
stances the heart may become ultimately fixed by adhesions
to the position which, however, it usually only temporarily
occupies. At first, after its displacement, it frequently palpi-
tates, and gives other evidences of its ability, but after a
short time it usually becomes evidently hypertrophied, and
after that performs its functions with more perfect regularity
and efficiency. It may also be displaced by growths within
the thorax, by cirrhosis of the lung, and by growth in the
abdominal side of the diaphragm, especially in the liver.

10. Rachitis. — This cause of changes in the walls of the
heart itself was first definitely pointed out by Rokitansky. He
observed that in cases where from deformity in the thorax,
usually commencing from the spine, the visceroe within it
were displaced, tlie heart was invariably hypertrophied.
Whether this is from mere displacement of the organs simply,
or whether an obstruction is created to the flow of blood by
the heart being at a new angle with the aorta attached to

HYPERTROPHY AND DILATATION. 63

the altered spine, or whether the aorta following the spinal
curve becomes altered and offers obstruction, or the heart is
itself encumbered by being placed in a position not normal
to it, is of little moment. Whichever cause is in action, or
if, indeed, as is probable, all are, the alteration in the shape
of the thoracic cavity is the real cause of the changes inaugu-
rated. . This connection of the heart with spinal caries is inte-
resting and instructive. For this is not uncommonly the" direct
cause of death to these unhappy sufferers, and the sufferer
from spinal caries which has become itself arrested, not
uncommonly dies with heart symptoms, anasarca, &c., the
consequence of obstructed and defective circulation, which
takes its origin again in the displaced heart and impeded
circulation, a secondary and ulterior consequence of that
deformity, which itself had ceased to be any longer a source of
danger. This condition of the circulation in sufferers from
rachitis should never be overlooked, and this knowledge of
the pathological consequences of rachitis will often enable the
medical attendant to be of service to the sufferer, which
could not be furnished by one unacquainted with this effect
of rachitis upon the circulation.

11. Pericardial Adhesion. — The compensatory value of
hypertrophy is nowhere better seen than in this condition.
Though the pericardial adhesion is sometimes most marked
along the track of this coronary circulation (Rokitansky), and
thus interferes with the coronary blood stream, and so leads
to fatty degeneration, in other cases a quite different result is
arrived at. The adhesion may be partial, by bands, which
are more or less stretched on each systole, or the adhesion
may be complete and the heart firmly encapsuled by the
adherent pericardium. So encumbered, the heart beats with
difficulty, and empties itself under disadvantages. But in
no long time hypertrophy of its muscular walls enables it
again once more to fulfil its function, and the palpitation, &c.,
which marked the earlier stages are no more found. Stokes
gives a case where, seven years after an attack of pericar-
ditis, the patient died, and the heart was found perfectly
encapsuled, and yet no symptom during life had evidenced
that anything abnormal had occurred with the pericardium.

64 THE HEART AND ITS DISEASES.

This power to add to its growth and to increase its power on
the part of the heart, when incommoded by displacement and
restrained by adhesion, is one of the most beautiful instances
of the power of the system to compensate evils which are irre-
mediable. That this sensation of inability to contract perfectly
should be in itself sufficient to procure increased growth,
and thus more perfect function, is an evidence of the great
reparative power which the organism possesses. That in
cases of general debility this reparative or compensatory
effort should be imperfect is no more then may fairly be
expected, and is in accordance with all experience of morbid
processes which run their course less restrained and checked
in organisms of feebler resistent or reparative power than in
others where this system is more equal to offering opposi-
tion to the downward course.

C. But the most marked hypertrophy with which we are
acquainted occurs, not when obstruction is offered to the
flow of blood forward, nor yet when the heart is displaced or
otherwise interfered with by surroundings, but when its
chamber is dilated, on diastole, under excessive, or, at least,
increased pressure. Under these circumstances, in a weakly
person, with little resistive power, the case assumes the
type of dilatation rather than hypertrophy, and quickly
passes on to its termination. But ordinarily hypertrophy is
the marked characteristic, not without dilatation, however ;
for increase in the distending power, if at all marked, leads
inevitably to increase in the size of the ventricular chamber.
But this distension evokes hypertrophy quickly, and to a
great extent. In fact no such hypertrophy is met with ordi-
narily as the hypertrophy of aortic regurgitation, the most
marked example. The flxct that distension produces an
impression which induces hyperplasia is well evidenced here,
and the more the pressure within the heart at disastole is
increased, as the case goes on and the valvular lesion in-
creases, so is the increase in thickness in the muscular walls.
But the increased pressure exercises a steady, distending, and
dilating force, which the hypcrtropliy can only limit for a
time, and on the structural integrity of the walls becoming
impaired, the process of dilatation is quickly resumed. The

HYPERTROPHY AND DILATATION. 65 5

two instances in which this form of hypertrophy is found are ^j^
aortic regui'gitation and mitral insufficiency. That the right . '^^
ventricle is also filled under increasing pressure in tricuspid j^ -1^
insufficiency is certain enough, but as this lesion is rarely ^^
found without left side disease, it is difficult to separate the ,^ -g
changes which may be due to overfilUng from the gorged tj
veins behind the imperfect tricuspid, and the effect of the <^ ^
left side changes. But in the other two cases we have well ^ , ^ '
marked and unmistakeable instances of hypertrophy, solely ^
called out to enable the left ventricle to withstand the in- Lg ;§
creased distending power to which it is subjected. •^1

12. Aortic Regurgitation. This is a familiar form of ^ ^
valvular lesion, and is usually accompanied by most marked ,5" ^ '
hypertrophy and dilatation ; indeed in this form of disease is ^ «::^ -^
found the cor taurinum. Here no obstacle is offered to the ' '^ /^ ^
flow of blood forward, but also, unfortunately, but little to '?^
flow of blood backward into the ventricle on the aortic <^
systole, or recoil. The blood once thrown into the elastic
aorta is normally arrested in the backward direction by the
semilunar valves. But when once these become imperfect,
then a stream of blood, small at first, but soon larger, is
driven back into the ventricle under the power of the aortic
recoil. This power far exceeds the force with which the
blood comes into the ventricle from the pulmonary j*«^iftft and
auricle. In fact this stream has a wedgelike distending
power before which the ventricular walls yield. But hyper-
trophy is soon inaugurated, and limits the distension by
offering an increased mass of muscular fibre to the distending
force. This for some time may balance matters, but the
imperfect arrest of the blood in its backward course on the
aortic recoil in consequence of this aortic insufficiency, leads
to imperfect filling of the coronary vessels. Thus, however,
the nerve apparatus may try to secure to the muscular walls
a more perfect supply of blood, this is prevented, and soon
the hypertrophy undergoes consecutive degeneration, and
the destructive distension, arrested by the hypertrophy, re-
commences. Here we see well how the hypertrophy acts in
limiting the distension, and also how, when it is arrested,
the dilatating process is again inaugurated. For this form

P

6{j THE HEART AND ITS DISEASES.

of hypertrophy is induced by the distension caused by the
addition of the distending force of the blood coming back-
ward from the aorta to the flow of blood coming in normally
from the pulmonary veins. But it is under increased pres-
sure of the distending force that we invariably get dilatation
along with the hypertrophy. Thus in aortic obstruction the
dilatation, if it exists, is so slight as to be unnoticeable, for
the increase in the muscular power enables the ventricle to
empty itself completely, while in aortic regurgitation the
dilatation from the increased distending force is well marked
and unmistakeable.

13. Mitral regurgitation. Here, too, we see an instance
of hypertrophy _, not to enable the ventricle to overcome any
resistance to the flow of blood forward, for none exists, but
merely to enable it to resist the increased distending force.
Here at each systole so much blood escapes backwards
through the mitral orifice, this is added to the bulk of blood
coming into the left heart from the pulmonary vessels, driven
in under an hypertrophied right ventricle behind. This addi-
tion causes distension of the vessels behind, and on diastole
the blood is poured into the flaccid ventricle under increased
pressure. This inevitably leads to distension and dilatation,
limited by hypertrophy. In many cases the hypertrophy is
early induced, and the cavity of the ventricular chamber is
not obviously enlarged, but in other cases, and more com-
monly, the chamber is increased in bulk, with more or less
thickening of the wall. This causation of the changes in
the left ventricle in mitral insufficiency, is well pointed out by
Niemeyer, and the more the subject is attended to, the more
marked does the connection become. This is, too, a very
pure instance of hypertrophy coming in to limit dilatation,
as no obstacle whatever is offered to the blood stream either
at the aortic orifice or in any part of the arterial system.
But as the distending force, though increased, is far from
having the force of the regurgitant stream in aortic insuffi-
ciency, so we see that, though the hypertrophy may be
distinct, it never attains those colossal dimensions found, not
uncommonly, in the latter form of valvular lesion. This
further demonstrates the connection betwixt distension

HYPERTROPHY AND DILATATION. 67

under increased pressure and the formation of hypertrophy,
by estabhshing the fact of the hypertrophy being propor-
tionate to the distending force ; where the force is Hmited so
is the hypertrophy, where the distending force is much in-
creased so is the muscular increase which is called out to
arrest it.

D. Hypertrophy following dilatation from temporary
causes of debility in the heart walls themselves. Here we
have no obstruction offered to the flow of blood, no increased
pressure on the flaccid ventricle, no displacement, or other
cause of impaired action from surroundings, but compensa-
tory hypertrophy surrounding dilatation, occasioned by
temporary causes, and again enabling the heart to fulfil its
function comparatively efficiently. The yielding which has
taken place in the heart-fibres during a period of debility
has, on the health and nutrition being restored, been followed
by increased nutrition and hypertrophy. This cause of
hypertrophy has not long been recognized, but Niemeyer
lays stress on this form of origin of hypertrophy. The chief
circumstances under which hypertrophy so rises are various.

14. Myocarditis of a latent character usually accompanies
both endo-carditis and pericarditis. But in pericarditis the
heart fibres become decidedly softened, for a period remain-
ing some time after the pericarditis itself has vanished. This
condition leads to a yielding of the heart walls to the
ordinary difficulties offered by the blood-stream, and to the
normal distending force of the blood pouring in from the
veins, especially in the left heart. Niemeyer has told us how,
on the health being restored, hypertrophy gradually sur-
rounds this dilatation, and a compensatory growth endows
the heart again with power to fulfil its function.

15. Exhaustion of the sympathetic. This is a common
cause of temporary inability in the heart and yielding of its
walls. It is obvious that all causes which exhaust the
sympathetic, as excessive tobacco smoking, excessive and
prolonged debauches, as seen in the feeble, rapid, compres-
sible pulse, common enough in delirium tremens, where the
heart is merely pumping a little blood off the top of its
contents, but nothing like a good ventricular contraction

F 2

68 THE HEART AND ITS DISEASES.

occurs ; in excessive coitus, in aggravated masturbation, in
exhaustion indeed, however produced. Here the heart is
feeble, asthenic, irritable, and inefficient, and temporary
dilatation ensues.

When this condition of dilatation becomes confirmed on
the restoration of the general health by removal of the cause
of exhaustion of the sympathetic, hypertrophy sets in. But
I am not certain that this new growth may not only enable
the heart to contract efficiently, but even lead to reduction
of the ventricular cavity to its original and normal dimen-
sions. Two cases tending to corroborate this view came
under my notice so as to make an ineffaceable impression.
It may not be out of place shortly to relate them.

J. T., an elderly and hardworking woman, was accom-
panying her husband for a walk in the country one Sunday
afternoon. On nearly reaching home he had a violent attack
of hoemoptysis, and in twenty days died of acute tubercu-
losis. She nursed him incessantly day and night ; what rest
she got being in an arm-chair. We know that there are so
many more beats per minute in the sitting than in the
reclining posture, and so, of course, so much less rest for the
heart. At the end of this time she was much exhausted,
and her legs were swollen. A few days afterwards she con-
sulted me, and presented all the physical signs of dilatation,
with a rapid, irregular, and feeble pulse. Under treatment,
in a few weeks all evidence of heart failure vanished. She
resumed her field labour, and eighteen months after this
presented no sign of cardiac inability.

T. A., set. 18, had engaged himself to a farmer for the
summer, and overtasked his strength persistently. He came
home, quite unable to work, with a weak, irregular pulse,
and a dilated heart. After three or four months of treat-
ment (digitalis and iron), he lost all his evil symptoms, and
Was again a first-class farm servant.

On the other hand, similar cases have remained with
obvious dilatation, helped, however, by some hypertrophy,
but leaving the patients somewhat incapacitated perma-
nently. This growth of tissue around dilatation arising
from temporary causes is a preservative, or rather conserva-

HYPERTROPHY AND DHjATATION. 69

tive action, which we cannot too much admire. That where
this causational condition persists the patients should remain
with dilated hearts and in a condition of great general
debility is no more than we could expect, when the system
is unequal to instituting hypertrophy.

These different causes pretty well comprise all the con-
ditions which give rise to hypertrophy. To the list must
merely be added two rare causes of hypertrophy. 1. Exces-
sive eating and diinking ; and 2. Lipoma (?).

16. Excessive eating and drinking. This cause of hyper-
trophy is stated by Niemeyer to be found in travelling wme
sellers, and Oppolzer states that the increased frequency and
activity of the heart's contractions lead in time to distinct
hypertrophy. A marked case of this kind occurred recently
in the Pathological Institute of the Vienna Krankenhaus,
which I fortunately saw. The man came into the hospital
with right side paralysis, and soon died with severe haemor-
rhage from the mouth and nose. A large clot was found in
the left hemisphere, and there was, too, a very large hyper-
trophied heart of textural soundness, without any apparent
cause for it, except his habits. As the arterioles were not
examined, it is possible some condition of them existed
which might lead to hypertrophy, but the whole subject
is obscure.

17. Lipoma (?). Flint relates a case of hypertrophy of
the heart, where the heart attained unusual dimensions, in a
young man (set. 23) of temperate habits, who died suddenly
with profuse haemorrhage from the mouth and nose. No cause
could be discovered for the hypertrophy in this case, and
Dr. Fleischl, one of Prof. Rokitan sky's assistants, suggests
the possibility that in this case there was a true lipoma of
the muscular structure of the heart.

These last two causes are so rare that, practically, they
need scarcely be regarded as connected with hypertrophy,
and certainly have nothing whatever to do with hypertroiDhy
as associated with dilatation.

All these previously mentioned causes, except tlie two
last, are common to both hypertrophy and dilatation, en-
tirely depending upon the general health, the nutrition, or

70 THE HEART AND ITS DISEASES.

the power of resistance as to which of them should predomi-
nate. For thoiTo;h certain forms are less associated with
dilatation than others, we find that in all, under unfavourable
circumstances and where the heart's nutrition is defective, we
have dilatation. It is impossible to separate hypertrophy
and dilatation in their causation ; in fact, it is probable that
dilatation, to a greater or less extent, invariably precedes
hypertrophy.

While these different causes lead to hypertrophy and
dilatation, we have some conditions which scarcely admit of
hypertrophy ever occurring, and so may rather be regarded
as causes of dilatation merely. These are chronic conditions
of debility, and especially those which are connected with
imperfect assimilation and persistent exhausting discharges.
Under these circumstances it is scarcely possible to expect
such a restorative effort as hypertrophy to be possible.

These conditions are chronic dyspepsia, chronic phthisis,
chronic uterine disease, chronic diarrhoea, or dysentery, &c.,
and also we frequently find dilatated hearts in those chronic
invalids who seem scarcely capable of maintaining an exist-
ence, even under favourable circumstances, and in whom a
state approaching to perfect health is simply out of question.
What more recent investigations into the action of remedies
upon diseased conditions of the heart may be able to do for
these unfortunates we can scarcely yet tell, but for many
cases there is an element of hope, even if not for others.
Often, no doubt, the general condition is dependent on the
feeble heart, in others the heart merely partakes of the
inherent general feebleness, and in the latter cases there
is less room for hope.

But there is one cause of dilatation which must be con-
sidered by itself, a most common and most serious cause ;
and that is degeneration of structure of the heart walls.
This occurs sooner or later in the great majority of cases
of hypertrophy, and often commences insidiously. It may
commence in atheroma of the coronary vessels, or defective
nutrition otherwise produced ; it may arise, the Germans
say, from chronic myocarditis ; it is possible that often its
origin lies in alterations of the structure of the cardiac

HYPERTROPHY AND DILATATION. 71

ganglia, but this a mere hypothesis, for of this subject we
know positively nothing; but whatever its origin, as soon as
it gains a footing the downward changes which the hyper-
trophy bad arrested recommence, we have dilatation and its
symptoms, and, as the disease is beyond the reach of any
remedy, the case soon passes on from bad to worse to the
final change. This is a cause of dilatation for which there is
no hypertrophy, no conservative change, and as soon as the
degeneration is sufficiently marked to be diagnosed, a prog-
nosis of the worst character is the only one which we can
any longer entertain.

We find, then, that from the various causes which induce
hypertrophy and dilatation that, according to the nature of
the cause, the rapidity with which it is formed, and the
general condition of the patient's health and powers, we
have different admixtures of the two, in varying proportions.
Traube has long classed these as perfect compensation,
first form, hypertrophy : imperfect compensation, second
form, hypertrophy with dilatation : and no compensation,
third form, simple dilatation. This is a practically useful
and dy^&ically correct division, though, of course, cases are
found of all grades and mixtures.

That piu-e hypertrophy is almost perfect compensation, so
long as it lasts, is certain, but when it begins to yield the case
passes from the first to the second division and downwards.

The second division is the most common, and is more or
less imperfect, according to the amount of hypertrophy and
dilatation comparatively. It is practically sub-divided into
the cases which are more correctly hypertrophy with dilata-
tion, and the others dilatation with hypertrophy, according as
one or other preponderates. The latter division trenches
closely on the last division of simple dilatation. The more
hypertrophy the better, invariably, the greater the dilatation
the reverse.

I am inclined, however, to think that when dilatation has
not long existed that a return to the normal size of the heart
is possible ; it being impossible to say that there is abso-
lutely no hypertrophy, but with no apparent hypertrophy.
In proof of this are the two cases given above, which might

72 THE HEART AND ITS DISEASES.

be added to, and also the experience of Fuller, who states
that after a three or four years' course of iron he has known
all the physical signs and symptoms of dilatation disappear.
This return to the normal size has certainly not in any way
an a priori improbability, for we have every reason to suppose
that the heart can become temporarily distended and recover
itself, and this is especially ^well seen in the right ventricle.

Subjective Symptoms. — The subjective symptoms of hyper-
trophy and dilatation vary considerably. When the hyper-
trophy is pure the patient is practically as good, that is, as
equal to exertion, as an ordinary person, the compensation
being perfect. But in the second form of mixed compensa-
tion a comparative amount of vigour only is permitted, and
the patient feels himself on exertion unequal to the efforts
and short of breath, while there is palpitation and not unfre-
quently irregularity in the pulse. This is of great importance
often in forming a diagnosis and prognosis. A heart may
present nearly all the appearances of health and yet the
diagnosis is doubtful, and some hesitation is felt as to its
perfect health. In these cases of doubt let the patient make
some muscular efforts, and the doubt exists no longer ; there
are shortness of breath and irregularity in the pulse, the
commencing failure can be detected, and certainty remains.
But where the amount of hypertrophy is small, and in the
third form, effort becomes simply impossible, and the dysp-
noea, and usually cardiac irregularity with palpitation,
arrest the patient's efforts at an early period. In ftxct, a
condition of cardiac asthma is soon induced, with lividity of
the lips, or even countenance, loss of power, and almost
syncope ensues.

The amount of urine passed by patients in these various
forms is interesting and instructive. When the hypertrophy
is good the amount of urine is normal, when the hyper-
trophy is mixed with dilatation^ the amount of urine is
lessened, while in the last form the bulk of urine is scanty
and much diminished.

This symptom is one on which non-professional persons
lay great stress, and from the amount of urine passed will
the patient and his friends calculate the prognosis for them-

HYPERTROPHY AND DH^ATATION. 73

selves, especially in more advanced conditions of disease.
Nor is this a bad criterion for the practitioner himself, for the
bulk of urine depends on the arterial tension, and the arterial
tension in turn depends largely on the force of the ventricular
contractions.

Obje.ctive Symptoms. — The objective symptoms of these
conditions are very important, and the correct reading of
them is of great use, especially when their import is under-
stood. Thus in perfect hypertrophy we find no objective
signs of its existence, and extensive hypertrophy may exist
without the patient being conscious of it. But a temporary
trial, an increase in the cause, or passing ill-health may lead
to palpitation, for which the patient consults his medical
man, and the hypertrophy is discovered. But it must always
be borne in mind that in hypertrophy of the heart palpitation is
always an evidence that the hypertrophy is insufficient, not that it
is excessive. This is a rule which may be excused being
placed in italics, and the remembrance of it will be useful
often. The immediate cause of that hypertrophy may be
temporary, but the palpitation shows that the heart is also
suffering under temporary incompetence. Palpitation is the
outward visible sign of internal incompetence, and as such
must be so regarded, whether found with hypertrophy or not.
The more advanced forms of symptoms of cardiac inability,
as irregularity and intermittency, are not commonly found,
though prolonged intermittency may occur in aortic obstruc-
tion, when the patient is suffering from great debility. Still,
the objective symptoms of pure hypertrophy are rather
wanting than present, and when present are indications of
feebleness. But when there is also dilatation, palpitation is
commonly induced by moderate effort, if at all sudden, though
all may be perfectly quiet, as long as the patient is at rest,
or exercise, or even labour be pursued quietly and steadily
without effort. Palpitation, too, is readily produced by gas
in the stomach and colon, or by accumulations of more mate-
rial contents in these viscera. Where the dilatation is the
more decided condition, this becomes well marked, and not
ouly is palpitation induced by moderate effort, but irregu-
larity is easily induced, and not imfrequently is found imder

74 THE HEART AND ITS DISEASES.

all circumstances and persistently. An occasional halt is very
common, becoming more frequent on effort, but even a few
feeble rapid strokes before the halt are not at all uncommon.
And during palpitation itself the irregularity becomes even
more marked. The more the objective symptoms of heart
failure manifest themselves, the worse the look out of the
case. And when the case is one of simple dilatation, all the
symptoms are aggravated, and a life of comparative rest is
alone tolerable. Here we get not only palpitation and irregu-
larity, the latter ever present, but even intermittency, the
long ominous halt on any exertion. The simply dilated heart
is ever irregular and unrythmical, with frequent halts and
beats of varying duration ; often a number of comparatively
steady, still feeble beats, then a small cluster of very imper-
fect contractions, then a distinct pause, and after that the
comparatively normal beats are resumed. Sometimes the
halt is not single, but repeated even more than once, before
the heart resumes its quasi normal beats.

This gradual downward progression is often seen in
elderly people when the heart begins to fail, and the first
irregular movements on exertion are followed by persistent
irregular action, and a permanent halting : then on exertion
more aggravated irregularity and the prolonged halt, then
the prolonged halt even when at rest, and along with this
gradual development of more serious objective symptoms, a
steady, downward progress : inde(id they go hand in hand
together, one illustrating the other.

It may not be possible for the student to recognise these
gradations at first, but a little care and comparison of cases
will soon give him possession of the alphabet, after which
he will soon be able to read complicated cases for himself.
But he must always bear in mind that these objective
symptoms indicate debility, a fact most difficult to entertain
about palpitation, where there is at first siglit apparent
violent action.

Niemeyer has well pointed out that, in cases of dilata-
tion of the heart from passing causes, the palpitation which
accompanied this condition passed away when it was sur-
rounded by hypertrophy, but that when that hypertrophy

HYPERTROPHY AND DILATATION. 75

was beginning to undergo degeneration, then palpitation
showed itself again. And when these objective symptoms
do show themselves after hypertrophy has existed some time,
their appearance is most ominous. Here, however, the evi-
dences of inability are more apt to show themselves in the
more insidious manner of irregularity and intermittency.
Palpitation is an active symptom of debility, not commonly
associated with degeneration of structure, but rather with
the struggles of an incompetent heart of textural soundness.
The presence of degeneration is not usually heralded by pal-
pitation, though palpitation is not incompatible with the
textural integrity of some fibres, while others are degenerate.
Degeneration is rather associated with positive loss of power
and instinctive consciousness of failing power in the patient.
Degenerate fibres are rather apt to manifest themselves by
more or less complete syncope on exertion, or by entire
failure of heart action permanently in diastole.

To sum up, we may say that in hypertrophy we have
few objective symptoms, rarely amounting to more than pal-
pitation ; that in hypertrophy and dilatation we are more
apt to have irregularity with palpitation on efibrt ; in dilata-
tion alone irregularity with intermittency increased by efibrt
along with palpitation is more commonly found.

Physical Signs of Hypertrophy. — Inspection. — On inspection
an hypertrophied heart will be found with a distinct and
localised apex beat considerably lower than the normal apex
beat, extending even to the eighth intercostal space, or
further, and decidedly to the left of the normal apex beat.
This is due to the elongation of the left ventricle, which
sometimes extends from one-half to three-quarters of an
inch beyond the right ventricle.

This elongation is peculiar to pure hypertrophy, and is not
so marked when this hypertrophy is combined with dilatation.
On palpation, too, this apex beat is felt well defined, power-
ful, and distinct. It is felt as a limited point forcibly driven
against the thoracic parietes at each ventricular systole. It
is quite different from the rounded obtuse heaving formed
when hypertrophy is combined with dilatation, and is cha-
racteristic of hypertrophy of the left ventricle.

76

THE HEART AND ITS DISEASES.

Percussion. — The information afforded by inspection and
palpation is corroborated by percussion. There is not such
marked increase in lateral dulness as in the direction of the
apex of the heart, and to the left. The increase in size and
shape in a well-marked hypertrophy, is shown in the accom-
panying plate, which is copied from von Dusch. The apex
is tilted, however, a little too much to the left side.

Hypertrophy of the left ventricle. The continuous line marks the normal
heart ; the dotted line the increase, a, h, Linca mamillaris sinistra.

(From von Duscli.)

Auscultation. — This last gives us very decided information
corroboration of the other means and the information
afforded by them. The decided heave, expressive of power,

in

HYPERTROPHY AND DILATATION. 77

is communicated distinctly through, the stethoscope, or even
to the naked ear.

The first sound is not quite so clear, perhaps, as the
normal sound, but is loud, somewhat prolonged, and partakes
of the character of a " thud." The muscular sound usually
covers the sound of the auriculo-ventricular valves, though
it is certain enough that their sound must also be increased
by the increased force by which they are closed by the
thickened ventricle. The aortic second sound, too, is dis-
tinctly accentuated when the hypertrophy is associated with
obstruction to the blood stream. . The increase in power,
and the strong muscular tone of the first sound, are of great
importance in distinguishing genuine hypertrophy from
counterfeits of it. Where associated with valvular lesion,
the first sound may be masked, and the diagnosis is formed
from the other factors. In aortic disease, the second sound
is interfered with, or its place totally supplied by a murmur
in aortic regurgitation.

Great aid, too, is derived from the pulse in hypertrophy.
It is usually firm, regular, well sustained, and incompressible ;
indeed it heaves up the finger on each pulsation, much as
does the ventricle the stethoscope placed over it.

As mentioned above, in pure hypertrophy there ^re
rarely any of the objective or subjective symptoms ; these
show themselves when the hypertrophy is failing, or in some
instances before the hypertrophy has become developed suffi-
ciently.

Physical Signs of Hypertrophy and Dilatation. — To inspec-
tion is visible a more diffused heaving than in true hyper-
trophy, and this^ too, not so markedly towards the left apex.
It may extend to the seventh intercostal space, and extend
considerably laterally. It is usually distinctly visible in an
ordinary person, and very distinct in a thin person. It is,K)f
course, more distinct in the intercostal spaces. i ,

Palpation corroborates the information received from in-
spection, and the diffused heave is distinct enough to the
hand, but it wants the marked force of true hypertrophy.
It is more decided, however, than the still more diffused slap
of simple dilatation, or where little hypertrophy is present.
It is somewhat irregular, and more so after exertion.

78 THE HEART AND ITS DISEASES.

Percussion. — By percussion we find that the lateral clul-
ness is decidedly increased, and that instead of the pointed
heart of hypertrophy, we have a more obtuse-angled triangle.
The dulness extends, too, more to the left of the apex-beat
than in hypertrophy, where the left apex is nearly the
furthest point to the left.

Auscultation. — In auscultation the first sound is often
clear, distinct, more approaching the normal than in hyper-
trophy alone. The muscular sound is not so preponderating,
and the sound of the auriculo-ventricular valves is not un-
frequently distinct, and can be clearly distinguished from the
muscular sound. The aortic second sound is often clear and
distinct, but wants the accentuation of hypertrophy. The
action of the heart is often rythmical when the patient is at
rest, but easily disturbed by exertion. Where the dilatation
is the more marked component, the action is tumultuous,
wanting in rythm, and tending to be irregular, a halt taking
place at distinct intervals, becoming more frequent on exer-
tion. The objective symptoms in hypertrophy and dilatation
are often marked, and palpitation is common.

The pulse is often full but wanting in firmness and rythm,
not so sustained, and more compressible than in hypertrophy.

Physical Signs of Dilatation. — To inspection simple dilata-
tion rarely yields any sign, except in very thin persons. In
those can be seen a still more diffused beat against the
thoracic parietes ; most visible in the intercostal spaces, not
usually so much below the sixth intercostal space, but de-
cidedly wanting in force. When seen it is commonly
irregular. Palpation yields much the same information as
inspection, the impulse is felt diffused, wanting in power,
rather partaking of the character of a sharp, feeble slap, and
extending over a considerable area.

Percussion notes that there is greatly increased lateral
dulness rather than increased dulness in the downward
direction. The area of complete dulness is considerably
increased usually, and the triangular shape of the heart is
now rather globular than otherwise. The area of incomplete
dulness is largely increased laterally.

The accompanying chart may aid in elucidating this
subject.

HYPERTROPHY AND DILATATION.

79

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80 THE HEART AND ITS DISEASES.

Auscultation. — There is something in a dilated heart
which, on auscultation, reveals itself by observation. There
is a peculiar sensation, of which it is impossible to give a
description in words. Either to the ear or stethoscope there
is a sort of diffused tumble against the chest wall quite
peculiar. It is accompanied ordinarily by an unique sensation
of rolling over, with a pause, which B. W. Richardson compares
to the sudden halt of strikers on an anvil, which it is not
unlike ; it has always, however, to myself seemed to re-
semble most a horse changing its feet when cantering,
makmg a pause, and then going on with the other foot first.
It is no doubt a pause which gives relief to the heart fibres.
In addition to these the first sound is short, clear, and con-
sists largely of the auriculo-ventricular sound. The im-
pulse to the stethoscope is feeble, and the want of rythm is
distinct. The pause occurs at intervals, and is more frequent
and repeated on any exertion. Palpitation is common, and
is very easily induced, and during it the halt becomes more
pronounced and even more prolonged. While the irregular
action often met with, consisting of a cluster of short, feeble
beats before the pause, is perfectly well marked. When there
is also fatty degeneration the first sound is very weak, and
there is marked intermittency.

Auricular Hypertrophy arid Dilatation. — Under no circum-
stances do we find the auricles with hypertrophy without
dilatation ; the opposite condition in the right ventricle is
not, however, unknown, and the auricle has been found to
consist of the layers of endo- and peri-cardium only with the
muscular fibres scattered and separate, so that the auricular
wall was partially transparent. Usually, however, we find
that there is dilatation with more or less hypertrophy, the
thickening often being considerable. The changes in the
auricle are almost always connected with disease of the
auriculo-ventricular valves. Thus in mitral disease the left
auricle becomes thickened as well as enlarged by the reflux,
or insufficiency, and by the opposition offered in mitral
stenosis. This hypertrophy in stenosis, no doubt aids to
bring out the prc-systolic murmur, Avhich is not, however,
always heard. This may be due to the fact that in mitral

HYPERTROPHY AND DHiATATION. 81

stenosis the endo-cardium of the auricle often becomes
thickened, opaque, and frequently sufficiently rigid to inter-
fere considerably with the auricular contractions. The
hypertrophy of the auricles is almost solely to resist disten-
sion, for the large orifice by which the veins empty them-
selves into the auricles offers a ready channel for regurgitation
on the auricular contraction. Still, the fibres of the auricle
do contract towards the auriculo-ventricular orifice, and thus
the direction of the contraction is favourable to the pro-
pelling of the blood towards the ventricle. The condition
of the auricles it is not at all easy to determine during life,
and it is usually surmised from the surroundings with which
it is found associated, as corroborated by what is found in
the autopsies. Of the left auricle, indeed, we can ascertain
very little positively, as it lies so behind the base of the
heart, and with the amount of lung covering it, any attempt
to map it out by percussion must almost be necessarily
schematic ; while as to any other direct way of examining
it, we possess absolutely none. So the left auricle can
scarcely be said to have any physical signs connected with
it. The right auricle is better within reach, and will be con-
sidered in the next section.

Physical Signs of Changes in the Right Heart. — Hypertrophy
is always, in the right heart, connected and found along with
dilatation ; and is the common concomitant of left side disease,
but not necessarily of left side hypertrophy. It depends on
the integrity of the mitral valve almost exclusively as to
whether right side changes should accompany left side
changes, or not. But the right side of the heart may become
hypertrophied without change in the left ventricle, and that
too not only in mitral stenosis, but in cases of lung affections
and other affections of the respiratory organs, as well as those
cases where obstruction is offered to the flow through the
pulmonary artery. The right ventricle has a tendency too
to be enlarged and thickened in swimmers, divers, gymnasts,
runners, &c., who tax the wind considerably. This obstruc-
tion to the flow of blood causes changes in the right
ventricle, and as long as the right ventricle grows and
strengthens the wind becomes longer, or, in swimmers'

G

82 THE HEART ANX) ITS DISEASES.

phrase, they " train on." But when the efforts become too
prolonged and severe, the right ventricle becomes distended
and less capable of forcing forward the blood, the wind
becomes shorter, or, as the swimmers say, they "train off.'
From these different causes the right ventricle alone may
become dilated and hypertrophied, and it must be remem-
bered that in consequence of its shape and evolution the
right ventricle is more prone to dilatation than the left. It
has been said, not untruly, that hypertrophy is the character-
istic of the left ventricle, and dilatation of the right ventricle.
Clinically this is the fact. In this condition of the right
ventricle the heart becomes much more relatively altered in
its position than in left side hypertrophy. It lies horizon-
tally almost in the chest, while, instead of the apex being
the most dependent part, a line may almost be drawn from
the apex across the ensiform cartilage to the cartilages of the
fifth and sixth right ribs. In fact the heart becomes more an
obtuse triangle lying upon its side than anything else.

The position and relations of the heart in this condition
is well given in the accompanying plate from von Dusch : —

To inspection, the beat of the heart is usually pretty dis-
tinct, diffused, and extending from the light apex towards,
and even beyond, the ensiform cartilage. There is commonly
enough no action seen towards the left apex, and, indeed, in
describing the signs here the condition of the left side will
be assumed to be normal. When there is both left and right
side hypertrophy, the characters of both will be found coni-
bined, and somewhat modifying each other.

Palpation notes that there is a diffused heaving, very
distinct, superficial, and not without force, extending from
the right apex in a direct line towards the third, fourth, and
fifth costal cartilages on the right side. It is not uncom-
monly accompanied by a distinct puls<ition towards the
second and third right ribs, which is indeed sometimes
visible, and which is caused by the action of the enlarged
right auricle.

Pejxussion, — This is a somewhat difficult matter when we
come to the right side of the heart. Firstly, however, we
get the negative evidence of the absence of left side enlarge-

HYPERTROPHY AND DILATATION.

83

ment, and the positive evidence that the apex beat is not
lower than its usual position, which make it pretty certain

* b

Fig. VI.

'■ K

f

Hypertrophy of right ventricle. The dotted outline shows the increase over
the normal size, which is marked by the continuous line.

that we have not left side hypertrophy to deal with. Thus
the increased action observed by inspection and palpation
must be, by exclusion, right side. Then there is the increased
dulness extending downwards more extensively than is
normal. But it is not safe to be very dogmatic about the
distinction betwixt heart and liver dulness along this edge,
and the action to palpation and the sound to auscultation
are safer guides, at least to the beginner. Still by percus-

G 2

84 THE HEART AND ITS DISEASES.

sion can be found a dnlness, more than normal, extending to
the right of the sternnm and along the area delineated in the
engraving. Very often from the second rib to the third
intercostal space can be found an area of dulness correspond-
ing to the enlarged right auricle. The area of increased
dulness is distinctly toAvards the right side of the chest,
extending to the right of the normal dulness, and corre-
sponding to the evidence furnished" by the other means of
examining the heart. The positive evidence furnished by
these three means, and the absence of evidence of left side
enlargement, constitute a fair ground for a diagnosis.

Auscultation. — On auscultation the first sound is heard
distinct and strong, with a sensation of superficiality about
it which separates it from the deeper seated sound of the left
ventricle. There is heard, too, at the ensiform cartilage,
often distinctly, the sound of the flapping together of the
valves of the tricuspid. This last is a point of some import-
ance in distinguishing hypertrophy of the right side. There
is also heard, too, the accentuation of the second sound at the
pulmonary valves. This point is of even more importance
in the formation of the diagnosis, and Skoda regarded it as
almost pathognomic of increase of size and power of the
right ventricle. These are the positive signs which guide
us, and there is the absence of evidences of the hypertrophy
being in the left side, as the non-effect upon the pulse, for
instance. This is a point to be attended to in the establish-
ment of the hypertrophy being upon the right side. There
is obviously increased action in the heart, not detectible in
the radial pulse, which would be the case if it were seated in
the left ventricle. There is not uncommonly excited action
or palpitation of this hypertrophied chamber, and even
irregularity in it, not traceable in the radial pulse. It is not
unusual to find, when the right side is affected, a somewhat
distinct irregularity in the heart to the stethoscope, when
there is no corresponding irregularity in the pulse, and at
other times a much more decided irregularity in the heart
than is to be found in the radial pulse, as if the left ventricle
only transmitted imperfectly the irregularity of the right
side. There is, too, great tendency to cardiac dyspnoea.

HYPERTROPHY AND DILATATION. 85

induced by slight causes, and not unfrequently with this
condition of the right side, chronic affections of the respira-
tory organs, especially such affections as impede the flovv^ of
blood, as emphysema, chronic pleuritis, or rather pleuritic
effusion, interstitial pneumonia, &c. The subjective symp-
toms of heart disease are never far distant, and exist in a
modified form even with tricuspid sufficiency, and, when the
tricuspid does become affected, follow quickly, with the jugular
pulsation, whicli is pathognomonic of tricuspid insufficiency.

The liver-pulsation which accompanies this condition, and
which may be caused either by venous regurgitation into the
liver, as stated, or by the systole of the right ventricle being
communicated through the diaphragm which separates it
from the liver, is a point on Avhich the Germans lay great
stress, and needs investigation by others.

These different points by which hypertrophy and dilata-
tion of the right side may be approximately distinguished
have been given somewhat at length, but it is to be hoped
not unnecessarily so. For the certainty of the right side
being so altered is often an element of hope, as regards time,
in left-side failures ; it is important often as showing the effect
of diseases of the respiratory organs ; and is finally often a
point to be noted as its subsequent failure, or passing away,
or the addition of tricuspid failure, are omens "of the most
unfavourable import.

Prognosis.— This is a somewhat complicated subject, as
the various conditions of hypertrophy, hypertrophy with
dilatation, and simple dilatation must always be regarded
in relation to their cause, to conditions which may have
arisen during their course, and their surroundings, the
patient's age, general nutrition, family history, &c. In
making a prognosis in each individual case all these col-
laterals must be considered, but in speaking generally of the
prognosis of these three conditions we must refer to the
condition of the heart itself.

In hypertrophy we find that the conservative effort has
a distinct tendency to maintain itself, by comparison with
the other less perfect forms of compensation. The more
complete compensation too not only is good in a prognostic

86 THE HEART AND ITS DISEASES.

view as regards duration of life, but also as regards bodily
power. In cases of obstruction to the flow of blood and of
displacement, perfect compensation may be attained and
maintained for years. Still the person could no longer be
considered a good life from an insurance point of view. In
other cases the compensation may be of only a temporary
character and soon pass away, as by the occurrence of
atheroma, by perverted or defective nutrition, or other
cause by which the nutrition of the heart may be affected.

In the absence of these causes of failure of the hyper-
trophy, a fair amount of health and vigour may be maintained
for years, and indeed as long as the hypertrophy can be
maintained. This is more important for those who must
take a considerable amount of active exertion in order to
procure a living, than those whose means enable them to
take life quietly. Where exertion is unavoidable, directions
should be given to reduce it to the minimum, for the hyper-
trophy will wear out soon enough without hastening the
event unnecessarily. Even under these circumstances, the
patient may maintain his ground for years, especially with
the aid of a little treatment occasionally. But in nraking a
prognosis we may often speak with confidence that no un-
toward result may be anticipated for a considerabJe time at
least, but repeated examination at intervals is desirable.
Hypertrophy is, however, liable to the risk of apoplexy,
especially when the arterial tension is increasing, and this
possibility must not be forgotten. Altogether, hypertrophy
is favourable to a more prolonged existence than is possible
under any other circumstances.

Hypertrophy with dilatation is assuredly a less perfect
form of compensation, and as such is neither so favourable to
duration of life, nor to capacity to undergo exertion. The
comparative amount of dilatation and hypertrophy and its
mode of origin, must guide us : where hypertrophy has
grown around dilatation from temporary causes of cardiac
inability, the prognosis is infinitely better than where hyper-
trophy is yielding, and dilatatiou setting in.

The amount of exertion which is unavoidable is of great
moment here, and all tjxertion exercises a malign influence

HYPERTROPHY AND DILATATION. 87

over the progress of the case. The avoidance of exertion
affects the prognosis favourably. Here the effect of nutrition
too is marked, and any temporary failure of nutrition has an
undesu'able effect. All causes, indeed, which tend to increase
that dilatation which the hypertrophy has arrested, affect the
prognosis, and should, if possible, be removed. In itself,
hypertrophy with dilatation carries with it a much worse prog-
nosis than hypertrophy, in direct proportion to the amount of
dilatation. There is no risk of apoplexy here, but some risk
of cardiac failure. Slight exertion is apt to induce unpleasant
symptoms, and temporary causes of exhaustion may be accom-
panied by alarming attacks of syncope.

In very favourable cases some capacity for exertion
may exist, but only to a limited extent, and the patient is
maimed for life, lateri hcesit lethalis arundo. In giving a
prognosis, it must be guarded as to time, and the importance
of avoiding causes which would tend to aggravate the disease
must be laid down with stress. Even with all care, the case
is an unfavourable one, though life may be prolonged for
years under favourable circumstances, for any intercurrent
disease is much more dangerous than to a healthy person.
Rokitansky holds an opinion that heart disease is protective
against phthisis and other diseases, but we must remember
that he is a pure pathologist and not a physician. All acute
disease is very dangerous to a person with hypertrophy com-
bined with dilatation, and may soon induce an increase in
the dilatation. In elderly persons who commence to feel
less equal to exertion, and in whom the heart is discovered
dilated even with considerable hypertrophy, the prognosis is
serious to life, hopeless as to cure, and if this advance in
spite of treatment, a fatal event is not far distant.

Dilatation, simple and without hypertrophy, is a condition
much worse, in every sense as well as prognostic, than the
two preceding divisions. There is not only incapacity for
all exertion almost, but the prognosis as to life is very un-
favourable. This feeble heart even during rest gives evidences
of its inability, and these are much increased by any neces-
sity for exertion. Fortunately, however, the general condi-
tion is such that exertion is rarely possible, and thus the

88 THE HEART AND ITS DISEASES.

risks arising from it are avoided. The case is rarely without
more or fewer of the subjective symptoms of venous stagna-
tion, and the congestion of the abdominal viscera renders the
sufferer an almost constant dependent on therapeutic aid for
some visceral complication or another. The condition of
dilatation is unfavourable even to its own maintenance, and
the oncoming of structural degeneration is ever threatening.
For this dilated heart is ever contracting feebly and ineffi-
ciently, and only pumping a small quantity off the top of its
contents into the aorta at each systole. The aorta is but
imperfectly distended, and therefore its recoil is slight ;
this aortic recoil is the propelling power into the coronary
arteries, and the diminished recoil entails an imperfect
coronary circulation, and that, in its turn, imperfect nutrition
of the heart itself. This is a great source of danger in dila-
tation, while cardiac syncope on exertion is another : indeed,
the danger of this syncope being fatal, depends much on
whether the walls are still structurally sound, or not. The
effect of intercurrent disease here is even more marked than
in the preceding division, and acute bronchitis is especially
liable to be fatal. The patient is indeed more or less a per-
fect invalid, and the prognosis to life is very unfavourable.
One class of cases alone have a prognosis not so very un-
favourable to life, and that is the elderly lady with means,
who often maintains an existence for years with a heart that
would be fatal to a seamstress in a few months. The prog-
nosis of simple dilatation is necessarily bad, and if the
symptoms of advancing degeneration of the heart fibre be
added to it, the duration of life is limited. Often in elderly
persons the advance of degeneration of structure will mani-
fest itself in dilatation with unfavourable objective symptoms
and increasing debility, and here the prognosis is of the most
unfavourable nature. In simple dilatation, palpitation is
almost a favourable symptom, as being to some extent an
evidence of structural soundness, while persistent irregularity,
with intermittency and attacks of syncope on exertion, is
of the worst omen.

Can hypertrophy ever he regarded as itself destructive ?
This is a question of some considerable importance, and must

HYPERTROPHY AND DILATATION. 89

be considered before any allusion can be made to the treat-
ment of these conditions. When it is to overcome obstruction
offered to the flow of blood, when it is to enable the heart to
contract more efficiently when hampered by surroundings,
when it is to enable a dilated heart to act more perfectly, we
may safely say it is not. But hypertrophy, and that too to
a very decided extent, occurs under one other set of circum-
stances, where its presence, though absolutely necessary on
one hand, certainly does mischief on another, and that is
when it is evoked to resist excessive distension.

This occurs either in mitral insufficiency or in aortic re-
gurgitation. In mitral regurgitation the hypertrophy is
rarely excessive, and even when considerable and combined
with dilatation, it is rarely destructive to the arterial system :
this is probably due to the escape of so much blood back-
wards through the defective mitral at each systole. But in
aortic regurgitation the case is much different, the increased
power with which the flaccid ventricle is distended by the
additional blood coming in under the force of the aortic
recoil, leads to dilatation which is only arrested by massive
hypertrophy. This dilatation and hypertrophy is usually
excessive, and at each systole a bulk of blood considerably
exceeding the normal, and often twice as large, is forced into
the arterial system under greatly increased pressure. This
leads to excessive, even if instantaneous distension of the
arterial system, as is well shown in a smygmographic tracing,
or evidenced to a finger placed on an artery. This excessive
distension leads to chronic thickening of the endarterium or
endarteriitis deformans, and general degeneration of the
arterial system. Not unfrequently this distension leads to
rupture of a cerebral vessel and thus to death. But this
general affection of the arterial system leads to loss of
elasticity, and thus to loss of recoil ; the coronary circulation
is thus diminished, an effect much aided by the imperfect
closure of the aortic valves, and the hypertrophied heart
soon again becomes the subject of thai dilatation which it
can no longer arrest in consequence of the degeneration of
its structure. Still even here the greatest danger is the loss
of hypertrophy, so that no treatment to reduce that hyper-

90 THE HEART AND ITS DISEASES.

trophy, even granting that it were possible, could not be
justified, as avoiding the Scylla of arterial destruction could
only run us on the Charybdis of cardiac failure.

Question of Permaneyicy of Hypertrophy. — This is an im-
portant question, and hes midway betwixt prognosis and
treatment, for if affected by treatment this must modify the
prognosis. The permanency of hypertrophy is of course a
question of comparativeness, and depends much on the sur-
roundings. We have just seen that it is of brief duration in
aortic regurgitation, and that too for causes which we can
readily understand. Under other circumstances it is usually
more permanent, next least perhaps when evoked to over-
come the obstruction offered by atheroma.

For here again the loss of aortic elasticity impairs the
coronary circulation, and leads to structural degeneration.
Under other circumstances it is usually more persistent, and
may continue unaffected for years, and thus enable the
patient to maintain a fair existence. Its maintenance depends
much on the general nutrition, and consequently in poor
people it is not so permanent as in those who can procure
good and sufficient food. It is more permanent in those, too,
who can maintain themselves without severe labour, which
tends soon to wear out the compensatory growth. Flint
expresses a decided preference for a moderate amount of
exercise in all persons who are the subjects of heart disease,
and states that their course is quickly downward where
exercise is no longer taken. I do not think that this state-
ment is liable to the obvious objection that their no longer
taking excercise is the result of an increase in then- heart
affection, a construction which might be put upon it, but
rather that a moderate amount of exercise is favourable to
the maintenance of the general health and nutrition, on
which so much depends. When we consider how intimately
associated the heart's labour is with exertion, we must see
that such exercise should be of that character as is least
likely to tend to fatigue and exhaustion.

Treatment. — Hypertrophy. In speaking of hypertrophy
and its treatment, after what has been said above as to its
causation and its nature, it is scarcely necessary to add that

HYPERTROPHY AND DILATATION. 91

all ideas of treatment, based on the assumption that hyper-
trophy can be reduced by remedial measures, must be aban-
doned. In the first place it is very highly questionable if it
be possible at all, except by the removal of its causation, and
for this latter there is some authority, as, according to Larcher
and Ducrest, the hypertrophy of pregnancy passes away on
parturition. But all plans of reducing hypertrophy by the
starvation plan, founded on Albertini and Valsalva's treat-
ment of aneurism, or by iodide of potassium, &c., must be
regarded as, fortunately for the patient, inoperative and
inert ; for, were it possible, it would merely substitute for
hypertrophy the much more serious condition of dilatation
which that very hypertrophy holds at bay, but which, so
soon as the hypertrophy is impaired, will immediately recom-
mence. Whatever troubles may be immediately caused by
hypertrophy, as in aortic regurgitation, must be submitted to,
for though rupture of an artery is not uncommon, by far the
most frequent cause of death in this condition is failure of
the hypertrophy. So to in atheroma of the arteries, as long
as there is good hypertrophy there is some risk of apoplexy,
but how much is the danger to life increased by the com-
bination of atheroma and dilatation, and the most perfect
hypertrophy in this condition all too soon is lost in degenera-
tion of structure from imperfect nutrition ; tlie diminished
recoil of those rigid tubes no longer filling the coronary cir-
culation. In hypertrophy the only treatment is such as is
likely to maintain it in its integrity, or, when it is not quite
perfectly compensating, such treatment as will conduce to
more perfect hypertrophy. In these conditions of not quite
perfect hypertrophy there is palpitation^ easily induced by
exertion. Here tonics, especially such as act directly upon
the heart, and produce more perfect ventricular contraction,
as digitalis, belladonna, &c., are indicated, and in practice
give prompt relief to the symptoms. But it must ever be
borne in mind that in these conditions, where the system un-
aided has nearly been able again to strike a balance of powers
by hypertrophy, much less of these agents will achieve the
desired result than where hypertrophy is combined with dila-
tation, a decided evidence of inability, and still more where

92 THE HEART AND ITS DISEASES.

hypertrophy is wanting altogether. Thus poisonous symp-
toms from comparatively small doses of digitalis are far from
uncommon where it is carelessly prescribed in large doses in
hypertrophy, while its use in much larger doses, continued
uninterruptedly for a considerable time in dilatation, is not
accomjDanied by any such symptoms of poisoning. To this
truly specific treatment may be added iron, vegetable tonics,
a liberal diet, and indeed all such measures as are favourable
to nutrition.

Hypertrophy with Dilatation. — Here decidedly more active
measures for the improvement and strengthening of the heart
walls are not only indicated but demanded. Much more
digitalis may be administered along with quinine, iron, or
strychnine,, and not rarely its accompaniment by arsenic, iron,
and cod-liver oil is indicated. For here we have imperfect
hypertrophy, not of a temporary, but of a permanent
character to deal with. Consequently, agents which will
directly increase the power and completeness of the ventri-
cular contractions are of the greatest service, and may, and
often must, be continued for prolonged periods of time,
months indeed, uninterruptedly. Whether a return to the
normal size of the dilated ventricles is often attainable is
perhaps doubtful, but certainly a much greater proportion of
hypertrophy can be so secured, and that is no slight matter.
For the more hypertrophy, the more perfect compensation,
and the less the liability to the recurrence of dilatation, as well
as the more bodily vigour, and the condition of general
health. Hypertrophy tends to maintain itself, while the
tendency of dilatation is as unquestionably to the inaugura-
tion of degeneration. In this combined condition there is
less capacity for exertion than in pure hypertrophy, and the
heart is more easily affected by exertion, and palpitation is
induced from slighter causes. Consequently exercise and
labour can only be permitted to a limited extent, and if
freely indulged in can only have the effect of hastening the
date when that hypertrophy will become imperfect, and the
dilatation arrested by its return. Thus it is desirable that
these patients should have their crippled condition explained
to llicin, and the necessity foi* limited exertion insisted on;

HYPERTROPHY AND DILATATION. 93

the more too because the baneful consequences are not
so much immediate, but rather remote, and thus apt to be
neglected.

In that form of hypertrophy with dilatation in elderly
persons, where are found irregularity at rest and palpitation
in slight effort, with increasing failure of the powers gener-
ally, which has been before alluded to, all treatment is but
temporary in its character, and rather palliative than curative.
This is not difficult to understand when we remember the
pathology, and consider that here there was in all probability
hypertrophy, which had given no sign, and that now this
hypertrophy is yielding to structural degeneration, which
permits of dilatation coming on, and which that dilatation
only aggravates, and the combination of the two quickly
bring about a fatal termination, which all and every treat-
ment is equally unable to avert.*

Dilatation. — The treatment of dilatation taxes all the
powers that can be brought to bear on it, and the success
which attends our efforts is very limited indeed, when regarded
from a curative point of view, and not very satisfactory
by any means when regarded from a palliative stand-point
merely. That more cheering results will follow from recent
investigations are within the limits of hope, when we know
that we do possess agents which not only conduce to more
perfect ventricular contraction, but by whose aid hypertrophy
may be furthered, if not indeed directly induced and fostered.
In many cases of temporary debility leading to heart failure
this is not so problematical, and we possess good grounds
for entertaining the view that compensatory and conserva-
tive changes may be inaugurated and maintained by remedial
agents, and an appropriate diet. But while thus hoping
about the future of some cases, we must admit that in the
majority of cases no such ground for hope exists, and all that

* A friendly critic, in reviewing my recent essay " On Digitalis : its Mode
of Action, and its Use," asks me " to distinguish, for him those cases in which
digitalis seems at first sight the proper remedy, but in which it fails and dis-
appoints us." This question it is not easy to venture to answer, but I am of
opinion that the failure often lies in the fact that the case is one where degene-
ration of the muscular fibres of the heart, of whatever kind, is underlying the
condition presented to us for examination and treatment.

94 THE HEART AND ITS DISEASES.

the most sangiune can hope for is that the destructive
changes may become arrested and Hfe be prolonged. This
prolongation of life is only compatible with the absence of all
exertion, and with a life of comparative quiet. Consequently
the prognosis amongst the poorer classes is very bad, and our
means of relieving them very inadequate to the necessities of
the case. Rest, nutritious and easily-digestible diet, are
absolutely requisite, and a residence in a hospital ward for a
few weeks often enables the sufferers to work on for some
time after in comparative comfort. These patients are much
benefited by a residence in a convalescent hospital, provided
that they have not much to do, or can be almost entirely
excused from labour. In patients of comparative means, the
effect of rest, absence from all exertion, and appropriate
treatment is often very encouraging. There is always, how-
ever, less hope in a case where there also exists a valvular
lesion. The addition of a valvular le^'ion subsequently was
at one time a source of fear, on the theory of the walls
yielding until the auriculo-ventricular valves were no longer
sufficient ; but Rokitansky states that in cases of dilatation
the valves and their attachments also stretch, so that such
incompetency does not occur in fact.

As to the treatment to be adopted, in addition to rest and
appropriate diet, it is a difficult subject, as the peculiarities
of each case must be studied, and the treatment adapted to
them. All discharges, that are at all exhausting, must be
attended to, and as these are often the consequence of the
defective circulation, treatment of the heart itself often is of
mateiial service in aiding the effect of the local remedies. The
more especial treatment consists of digitalis in combination
with vegetable tonics, mineral acids, or chalybeates, accord-
ing to the indications : when the appetite is feeble, and the
stomach not quite what could be wished, the addition of the
vegetable tonics and acids is indicated : when digestion is
good, iron may be combined with digitalis, and the general
nutrition aided. When there is much acidity in the stomach,
the iron may be advantageously exchanged for alkalies for a
time, or some preparation of it resorted to which goes well
with alkalies, as the potassio-tartrate of iron.

HYPERTROPHY AND DILATATION. 95

Cod liver oil may be tried where it does not disagree with
the stomach, and is a well-known useful adjunct in helping
the formation of muscular fibre. Where it disagrees, cream
or some of the new preparations of cod liver oil, in forms less
offensive than the natural, may be resorted to. During the
usually chronic progress of the case, a great variety of
measiu*es may be indicated, and many changes made, and
often a reversion to some discarded measure may be advan-
tageous. Still, while neglecting no measure which may be
of service to our patient, it is scarcely necessary to keep them
constantly under treatment, but, when in a comparatively
fair state of health, they may be allowed a remission of treat-
ment, and merely pursue a regulated diet, &c. Not, however,
is this advised on any theory of the necessity for these inter-
vals in the administration of digitalis, for in some cases this
is found impossible, and it is positively demanded by the
patient : indeed, the so-called cumulative action is beneficial
in dilatation, though it is quite likely to produce poisonous
symptoms when persistently administered in hypertrophy.

96 THE HEART AND ITS DISEASES.

CHAPTER VI.

Affections of the Endocardium : — Acute Endocarditis —
Ulcerative Endocarditis— Chronic Endocarditis.

Acute Endocarditis, — In describing tlie affections of the en-
docardium, some difficulty is experienced in drawing a line
betwixt acute endocarditis and the more chronic process.
The acute runs on into the chronic malady by a gradual
process which leaves no marked division-line ; but it is per-
haps most desirable to describe as acute endocarditis what
changes are usually found at the time, and within a short
time after the acute inflammation, and as clironic endocar-
ditis, the more gradual changes which are produced in
time.

Acute endocarditis is, as its name implies, an acute inflam-
mation of the living membrane of the heart, which is con-
tinuous with the endarterium, with which it is homologous.
This inflammation of the living membrane of the heart is
chiefly associated with acute affections, in which the blood
itself is altered, as in acute rheumatism, Bright's disease,
pyoemia, septicoemia, the acute exanthemata, and typhoid
fever. It is thus found along with conditions of blood-
poisoning with ostensible, or rather material agents. Whether
these act as direct irritants to this serous membrane, or not,
is not ascertained.

But we cannot feel surprised that we should have endo-
carditis when we have poisoned blood rushing through the
heart, or that the worst form should be found in pyoemia,
where Yirchow has found the blood to have an acid reaction.
In the most common forms of endocarditis, seen in acute
rheumatism and chronic Bright's disease, the blood is also
laden with an acid poison (lactic and uric acid), but not to
the extent to alter its reaction. But it would appear that
when the blood is so rendered less alkaline, we have a

AFFECTIONS OF THE ENDOCARDIUM. 97

marked tendency to endocarditis. But how it is brought
about we have as yet no evidence : it may He in the lessened
alkaHnity, or in the positive presence of acid blood poisons.
So common is it in acute rheumatism, that Bamberger has
calculated it to amount to 20 per cent, of all cases, a some-
what high percentage, probably due, in some degree, to his
purely expectant treatment.

Patliological Anatomy. — The first stage is that of injection-
redness, where the endocardium is injected, with points of
branch-like vascularity. This is rarely seen, in consequence
of the fatality of endocarditis lying rather in its consequences
than its immediate action. This inflammatory injection must
not be confounded with the mere staining of the endocardium
with the colouring matter of the blood, a post mortem occur-
rence which not unfrequently happens, and where the endo-
cardium is somewhat dull and of a dark red, or almost crimson,
colour. The inflammation is not effusive, but belongs to
what Virchow calls " parenchymatous inflammation " or the
development of young cells without fluid. The serous mem-
brane swells and is thickened, especially the free edges of
the valves, and contains these soft young cells in its sub-
stance and beneath it. Among these cells are fine fibres and
spindle-shaped cells. On the surface of the endocardium are
found vascular growths, villi, often in small aggregations,
giving the surface a warty appearance. These again must
not be confounded with the mere fibrinous adhesions to the
surface of the valves from deposit of the fibrin of the blood.
These fibrinous vegetations, so called, are not villi, but mere
strings of fibrin, and are usually found on that surface of the
valves over which the current of blood rushes. The fibrinous
deposits are far more apt to be detached and form emboli
than the villous excresences which are the result of the
endocardial inflammation. The endocardial inflammation is
usually general, and is accompanied by more or less inflam-
mation of the muscular structure beneath it. This myocar-
ditis may extend some depth into the muscular structure,
and by weakening it and altering its consistency, lead to
bulging and the formation of a true ventricular aneurism.
Endocarditis is often found along with pericarditis, or rather

H

98 THE HEART AND ITS DISEASES.

they botli take their origin ordinarily in the same conditions,
and the intervening muscular structure is usually involved.
The musculi papillaries are usually affected not only by the
inflammation spreading over their surface, but also by their
structure becoming involved. This leads frequently to
irregular action in them, and to insuflicient closui'e of the
valve, especially during the early stages of the attack. In-
deed, in acute rheumatism, irregular action of the musculi
papillaries is not uncommon without any evidence of endo-
cardial inflammation remaining.

As to the further progress of endocarditis to avoid repe-
tition, it will be considered under chronic endocarditis.

Symptoms. — Endocarditis often runs its course without
giving any evidence of its existence, except such as is fur-
nished by auscultation. In acute rheumatism this statement
contains no inherent improbabihty, as the patient's attention
is fully occupied with the painful joint complications. That
there should be no pain is not so unlikely, in consequence
of the slight nerve supply of the endocardium, for this is
nearly, not wholly, wanting. This accounts for the absence of
pain in endocarditis, and, for a similar reason, there is little
pain connected with pericarditis itself. There isu^o tender-
ness on pressure unless there is also m^bc^raitis. At first
the heart's action is somewhat excited, and the pulse is full,
but this is only during the irritant first stage of the inflam-
matory process. When the inflammation has aflected the
muscular structure of the heart, there is evident loss of pro-
pulsive power, though there may be excited action of the
heart and palpitation. Indeed, it would be somcAvhat
opposed to what we know of palpitation if it were not
present during this period of cardiac impairment. But this
evidence of laboriousness is usually present, and the heart's
inability is detected by the compressible feeble pulse which
characterises the later stages. The inflamed valves being
soft and thickened, do not produce so clear a sound as when
in health. From this and the defective muscular condition,
the first sound of the heart is muflied, dull, and wanting in
clearness. This sound, too, is usually further masked by a
murmur at the apex due to mitral regm'gitation. This may

AFFECTIONS OF THE ENDOCARDIUM. 99

arise from valvular insufficiency, but is more probably due to
irregular action of the musculi papillaries, which sometimes
causes a murmur when no evidence of endocarditis is fur-
nished, then or after. If, then, this irregular action is found
without inflammation, it is more than probable that it is in
action when there is. And, on the other hand, it is difficult
to account for valvular insufficiency from change in the
valves themselves, as this distorting and mis-shaping action
of endocarditis is one of its later and not its earlier actions.
The murmur may, however, arise from old standing valvular
disease, and when so occurring, is decidedly troublesome
from a diagnostic point of view. There are, however, points
by which it may be diagnosed, approximately, at least ; thus,
Avhen old standing mitral disease is present, there is old
standing enlargement of the right side of the heart and
accentuation of the pulmonary second sound.

As, however, mitral insufficiency, from the irregular action
of the musculi papillaries, would soon make the diagnosis
more complicated, it is desirable in all cases of acute rheu-
matism to examine the heart carefully at the first visit, so as
to prevent any after confusion. For this mitral insufficiency
soon leads to accentuation of the second sound at the pul-
monary orifice, and to excited action of the right ventricle.
The right ventricle, then, being distended, gives an increased
breadth of cardiac dulness on the right side, and thus a con-
dition of right side enlargement is simulated. The general
symptoms of this condition are general malaise, anxiety at
the precordia, tendency to delirium, and the general feverish
symptoms. When there is mitral regurgitation, the pulse is
often irregular in volume, and must be distinguished from
the irregularity in time of the heart when enfeebled by the
accompanying myocarditis. When the attack is more ad-
vanced there is weak feeble pulse, difficulty of breathing,
congestion of the lips, and indeed the general symptoms oi
venous congestion.

The temperature is increased, and may show variations
betwixt the morning and evening temperature of two or
three degrees. The temperature is not commonly above
103^ or 104° in the evening, but in consequence of the occur-

H 2

100 THE HEART AND ITS DISEASES.

rence of acute endocarditis -with acute rheumatism, it is diffi-
cult to fix a temperature as that of the endocarditis. The
same holds good in the acute exanthemata pyoemia, puer-
peral fever, and the sceptic conditions along with which
endocarditis is found.

Prognosis. — The prognosis of endocarditis is usually good.
AVhen occurring with acute rheumatism it is rarely or never
fatal, and certainly not directly fatal. In Bright's disease it
is also, in itself, not a source of immediate danger. In puer-
peral fever, in pyoemia, and sceptic conditions, the prognosis
lies rather with the conditions than the endocarditis, and is
very bad. The prognosis of endocarditis is altered by, and
depends on, embolism. This complication is not rare, and
may occur in any case. It depends on the washing loose into
the current of blood one of the fibrin-deposits found along
with endocarditis. Probably the inflamed surface attracts
the fibrin of the blood more than uninflamed endocardium,
and these form on the surface of the valves, oyer which the
blood rushes, and are thus liable to become detached by the
blood current. As the endocardium becomes inflamed chiefly
over the mitral valve, and less commonly the aortic valves,
and still less rarely the valves of the right heart, except in
intra-uterine life, when the riglit heart is affected more than
the left, these vegetations are chiefly located on it, and when
so located may give rise to a presystolic murmur as the blood
rushes over them. Thus, when detached, they pass into the
general arterial current and float along till arrested in some
artery which becomes too small to allow of their further
passage. Here the embolon lodges, and cuts off the circula-
tion, and results in necrosis of the part whose blood supply
is thus arrested. The most common situation in which an
embolon is arrested is the spleen, next the kidney, and after
that the left middle cerebral artery. When then in endocar-
ditis there are rigors, and evidences of any of these three
occurring, as in spleen embolism, pain over the spleen,
tenderness, and swelling ; in the kidney, albuminuria, or pain
over the loins, &c. ; and in the brain, hemiplegia, aphasia, *ic.,
there is ground for supposing tliat an embolism is formed.
The embolon may lodge in the femoral artery, in the

AFFECTIONS OF THE ENDOCARDIUM. 101

coronary circulation itself, in the liver, mesenteric artery,
and small ones even in the artena retinae centralis. These
embolisms and their consequences form the chief danger in
acute endocarditis arising from the endocarditis itself.

The treatment of acute endocarditis will depend much on
the affection with which it is associated. If with rheumatism,
it is difficult to say, but this will be considered in the treat-
ment of pericarditis, to which the reader may refer. In
pyoemia and these conditions little but stimulants, &c., can
be prescribed. In the acute exanthemata and in Bright's
disease it will follow the treatment of the general conditions.
There are no special means of affecting endocarditis, and
bleeding, leeches, and the administration of mercury by
inunction, and otherwise, against which Niemeyer is energetic,
are probably more decidedly harmful than anything else.
The same may be said of cold applications to the precordia.
The chest should be kept warm, and be as little exposed in
examination as possible. When there is failure of the heart,
and defective circulation, digitalis may be administered.

Ulcerative Endocarditis. — Ulcerative endocarditis is a ma-
lignant form of endocarditis, not, however, apparently asso-
ciated with any special zymotic or sceptic condition. It is
common, however, under conditions of grave blood-poisoning,
as in pyoemia, puerperal fever, &c. As it has been especially
studied by Germans, and mostly in Berlin, the reader must
pardon my giving an abbrievation from the account given by
von Dusch (Lehrbuch von Herzkrankheiten).

This form of endocarditis commences with redness and
injection of the tissue beneath the endocardium, which is
swollen by a parenchymatous infiltration of connective tissue
elements. There is also a free exudation from the surface,
which is washed away by the blood stream. The epithelium
is removed and the surface is dull, no longer smooth, but as
if covered with fine felt. From the connective tissue arise
white gelatinous mucus-patches, which appear on the surface
of the valve as white granulations, having a greyish-red
shade. These undergo a fatty degeneration, with a dissolv-
ing of the connective tissue, and are washed away little by
little in the blood-current, and form superficial ulcers. These

102 THE HEART AND ITS DISEASES.

are accompanied by greater or smaller collections in the
valves which force up the endocardium and perforate it in
spots, forming a purulent myocarditis. In other cases there
is fatty destruction of the connective tissue with formation
of pus in fine, small, yellow points. These pass on to a
molecular necrosis of the endocardium with destruction and
the formation of ulcers. This may lead to ulcerative de-
struction and tearing of the valves. When this occurs at the
basis of a valve, it may cut loose a portion of the valve
which floats freely in the blood : it has been known to sever
a portion of the demolished valve, which has been washed
away by the blood-stream. It also may destroy either the
tendinous or muscular portion of the musculi papillaries, or it
may also perforate the aorta valves and open the pulmonic
and systemic chculations into each other. In other cases by
perforating one surface of a valve, it may lead to aneurism
of the valves ; and where there is ulceration extending into
the muscular structure of the heart, ventricular aneurism is
formed.

Acute ulcerative endocarditis is seen either as a general
blood-poisoning with typhoid symptoms and adynamic fever,
or under the cover of the symptoms of pyoemia with the
heart symptoms in the back ground. It is accompanied not
uncommonly by other acute affections, as pericarditis, myo-
carditis, pneumonia, or pleurisy, and by numerous metastases.
In most cases there are initial rigors with hot fits succeeding
them, and at first these may have regular intervals, daily, or
more frequently, resembling an intermittent fever : or the in-
tervals may be irregular. Death may take place during the
prolonged initial rigor. These rigors are succeeded by fever,
and perspiration which gives no relief. In time the fever
becomes more continuous, with slighter rigors. At the com-
mencement there is vertigo, headache, great muscular weak-
ness, and prostration. The pulse mounts up to 130 or 150,
sinking sometimes suddenly to 80 or 90, and small and irre-
gular. The temperature is 107°, the tongue dry ; there is
delirium, a drowsy condition, and stupor. There may be
sudamina, and often is observed an almost roseolar exan-
them, sometimes even papular or pustular, with more or less

AFFECTIONS OF THE ENDOCARDIUM. 103

general ecchymoses in the skin. The appetite is lost at the
commencement, there is vomiting and diarrhoea with algor
and cramps in the calves before death. In many cases there
is jaundice from blood alteration, with metastasis to the liver,
or parenchymatous inflammation of it. There is also
enlargement of the spleen, with tenderness over it and the
liver. The urine is scanty, saturated, and often coloured
with bile, and frequently contains albumen. The patient
may have oppression and pain in the praBcordia with marked
dyspnoea, choking, and orthopnoea, or there may be no sub-
jective symptoms. When combined with pneumonia or
pleurisy there are pains in the side, cough with frothy expec-
toration, blood-tinged, and the physical signs of these
affections.

Among the objective symptoms are a systolic blowing
murmur, or it may be diastolic : the heart's sounds may be
obscured by exudation in the pericardium. On percussion
there is general increased heart dulness. Death commonly
occurs from the adynamia passing into coma, or is sudden
from the tearing off of the valves and chordae tendineae.

Prognosis, — The prognosis is very unfavourable indeed,
and the progress of the case to its termination is rapid.

The Diagnosis. — This affection is closely allied in symp-
toms to typhoid fever, in the enlargement of the spleen, the
diarrhoea, roseola, delirium, and stupor, and is distinguished
from it by the prolonged rigor and intermissions, and by the
positive evidence as the case proceeds, and the intermissions
are lost, of the presence of mischief within the heart.

The treatment has consisted of stimulants, ammonia,
wine, camphor, and musk, and the administration of quinine
in large doses in combination with opium ; the subcutaneous
injection of morphia, and the external use of ice and salt.

Chronic Endocarditis. — The pathological changes described
under acute endocarditis may pass on into a slower chronic
condition, which, however, commonly occurs without any
initial acute inflammatory action. The acute inflammation,
with its thickening of the endocardium and its villi over its
surface, passes away, and a condition of much less vascularity
takes its place. The injected and redened endocardium

104 THE HEART AND ITS DISEASES.

becomes paler, and ultimately an opaque white membrane, or
may simply lose its vascularity and resume its natural ap-
pearance with the distorting action going on beneath its
surface. But, soon, all characteristics connected with acute
endocarditis pass away, except it be in a more rapid destruc-
tive process than when purely chronic, but presenting no
naked eye changes to distinguish it. The chronic process
is a distinctly parenchymatous inflammation, slow, and having
none of the characteristics of inflammation, except it be
sometimes " swelling." The development of connective
tissue slowly, with its contracting, distorting action, is the
characteristic of chronic endocarditis. At other times there
is distinct increase in bulk, owing to a more free development
of cell elements, especially in the free edges of the valves,
which become rounded, hard, and incompressible. On the
semi-lunar valves it may take the form of festoons along
each valve. But any increase in bulk is ultimately more or
less reduced by the contracting process so peculiar to con-
nective-tissue elements.

It may be convenient to describe in turn the process as it
goes on in the auriculo-ventricular and semi-lunar valves.
In the mitral valve are the changes due to chronic endocar-
ditis most frequently seen. They may proceed in two
directions towards drawing the valves in the direction of
their musculi papillaries, or in a direction towards each other,
by the agglutination of their free surfaces. In the first case
the process goes on not only over the valves themselves,
but along the endocardial covering of the tendinous cords of
the musculi papillaries. This process is frequently confined
to one valve only with its cords, and by preference the valve
of the fixed wall. In the mitral it more commonly attacks
the valve of the fixed wall and the small sheet-like patch of
endocardium, with fibrinous threads glittering through it,
which belongs to the fixed wall valve of the mitral, and ex-
tends into the aortic valves on that side. The contracting
process may draw the free edge of the valve down to the
points of the papillary muscles themselves, or the action may
lead to withering and absorption of the musculi papillaries
themselves, and the valve is fastened down to the muscular

AFFECTIONS OF THE ENDOCARDIUM. 105

wall of the heart by the tendinous cords merely, and is so
generally contracted that the tip of a finger only can be
inserted betwixt the wall M,nd the valve. This last action is
not uncommon in the mitral, and is perhaps the most com-
mon pathological process in the tricuspid.

At other times the chronic process gradually approxi-
mates the free edges of the valves, commencing from theu'
extreme edges and gradually gluing together the free edges
until ultimately all trace of two valves is lost, and there is
either a firm curtain, merely perforated in the centre, dividing
the ventricular and auricular chambers, or at other times the
process draws the two valves with their cords and muscles
together into a perforated cone, extending into the ventricle,
with a rough edged perforation into which a finger cannot
be passed. The closure is sometimes so advanced, ere death,
that the orifice is merely a slit, termed '' a button-hole "
mitral. Usually behind this, the inflammatory process has
spread over the surface of the auricle and converted the en-
docardium into a firm white opaque lining, so rigid as to
prevent the auricle from collapsing : this process extends
into the pulmonary veins, and is due probably to the stretch-
ing of the parts from the obstruction in front offered to the
flow of blood ; in this it is allied to the atheromatous changes
in the lining of veins when distended by an artery opening
into them. This stenosis produced by chronic endocarditis is
confined to the mitral valve, and stenosis is yet unknown in
the tricuspid. Changes in the mitral valve produced by
chronic endocarditis are not uncommonly accompanied by
tricuspid insufficiency from a similar cause.

In the semi-lunar valves this chronic inflammatory process
becomes very frequently a true chronic valvulitis, not affect-
ing any other portion of the heart. It is an insidious com-
plaint, without subjective symptoms of its own, and slowly
works the destruction of the valves, causing either stenosis,
or simple insufficiency, and commonly a combination of the
two. Usually when seen at an early stage, the free edges of
the valve are thickened, round, and cordlike, yet capable of
almost complete closure. The corpora arantii soon become
obliterated and lost. The contracting action often, acting on

106 THE HEART AND ITS DISEASES.

this cord, diminishes the size of the valves, so that on the
aortic recoil they can no longer approach each other. The
tendency here is to contract each valve individually, and
draw them towards the walls of the aorta, and thus, while
offering no obstruction, or little, to the forward rush of blood
on the ventricular systole, to offer no obstruction to the
backward rush of blood on the arterial recoil. Where this
tendency to contraction of each valve is marked, the case
runs its course rapidly. At other times there is fulness of
the free edges of the valves, with somewhat of shrinking, so
that the edges no longer approximate and insufficiency
occurs, and this is accompanied by thickening of the valves
generally and more or less rigidity, so that there is also an
obstruction, and systolic murmur, from the rigid valves not
bending back before the blood-current. At other times there
is rigidity of the valves gradually becoming more and more
perfect, with agglutination of the edges of the valves until
the orifice is distinctly narrowed, so as to offer great obstruc-
tion to the flow of blood through the valve either forwards
or backwards. This may proceed to great length, ere death,
and has gone so far that a probe could scarcely be passed
through the aortic orifice. At other times this rigidity fixes
the valves before such contraction has been reached, and
from these rigid free edges grow tubercles of chalky matter,
extending over the orifice, and still further impeding the
blood-current. At other times it may glue together two
valves, and these, stretching across, oppose both flow and
regurgitation. From the convex side of these valves being
presented to the blood current from the ventricle as long as
any flexibility remains, it is in favour of the normal current,
while the concave surfaces being presented to the backward
rush of blood, regurgitation is opposed. In each case it is
prognostically important to ascertain how far the lesion bears
the character of obstruction or insufficiency.

Valvulitis is not always confined to one valve, and aortic
disease often becomes complicated by the process spreading
to the mitral valve, and vice versa. It may sometimes extend
from aortic valves to pulmonary, but this is scarcely direct
extension through the arterial coats. The pulmonary valves

AFFECTIONS OF THE ENDOCARDIUM. 107

themselves are rarely affected, especially when not subjected
to increased strain from pre-existing disease of the left side.
This corroborates the view that valvulitis usually arises from
the force with which the valves are closed, aided, no doubt,
by favouring dyscrasial conditions.

When this proliferation of connective tissue elements has
existed some time, it undergoes degenerations itself. This
may be by excessive deposit of earthy salts in it, or by ab-
sorption of the other elements, the salts remaining. There
remains a petrified condition of the valves, often with cretified
masses, the remains of outgrowths, attached to the diseased
valves. These last very commonly line the diseased valves,
both mitral and aortic, and make the edges rough and irre-
gular, aiding much in the production of loud murmurs,
especially systolic. At other times this calcification goes on
with certain connective tissue corpuscles enclosed in it, and
then a process, closely resembling petrifaction is inaugurated,
the valves being hard and stony. This is probably what
older writers described as " ossification of the heart," rather
than any development of bone within the walls, as is normal
in some animals, and commonly seen in the heart of an elderly
ox or cow ; though this does occasionally occur. This ossifi-
cation, or rather petrifaction, is persistent. In other cases
the new tissue undergoes fatty degeneration and the forma-
tion of cholesterine scales, as in the degeneration of an athero-
matous arterial patch.

Frequency in Valves affected. — This is important diagnosti-
cally, as well as interesting pathologically. When chronic
endocarditis is a prolongation of acute endocarditis, which
was co-existent with acute rheumatism, the mitral valve is
almost invariably the one affected. Others may be affected
along with it, as the aortic valves, and more rarely again the
tricuspid ; the pulmonary probably almost never. But in
advanced life, when a chronic valvulitis is common at the
aortic orifice, the order is changed, and the mitral is less
commonly affected than the aortic, but often becomes affected
secondarily to the aortic valves. When there is old standing
disease of the left side of the heart or of the lungs, and there
is dilatation of the pulmonic vessels with enlargement of the

108 THE HEART AND ITS DISEASES.

right side of the heart_, then we get valvuHtis of the pulmo-
nary valves. This is not commonly seen, as here is often
tricuspid endocarditis, and the accumulation of evils carries off
the patient before the pulmonary valvulitis becomes marked.
This tricuspid inflammation is also due to the enlargement of
the right ventricle and the more forcible closure of the tri-
cuspid. Thus tricuspid lesions are not rarely found in con-
nection with mitral lesions, but very rarely as a primary
lesion, and then usually with old-standing disease in the
lungs, or as remains of intra-uterine affections.

Elaborate tables have been formed of statistics of the
comparative frequency with which the valves of the heart are
affected. The only one at hand is from von Dusch, but
will illustrate the relative frequency as well as a larger col-
lection, for the relative frequency is, within certain limits,
pretty regular.

Willigk found the relative frequency of valvular affec-
tions, in his experience, to be mitral disease 36 ; aortic
disease, 22 ; tricuspid, 8 ; pulmonary, 2. Flint found mitral
disease 40 ; aortic, 37 ; of both combined, 14 ; tricuspid, 4 ;
Cockle, mitral disease 90 ; aortic, 71 ; both combined, 17.

CEtiology. — These tables indicate the probable cause, as
well as the relative frequency. Mitral disease is most com-
mon, being the result of acute rheumatism, the great pro-
voking cause of endocarditis. Next comes aortic disease,
associated rather with advanced life, and thus with atheroma
of the aorta, and frequently with gout. Then comes the
union of aortic and mitral disease, in most cases probably
due to the effect upon the mitral of the aortic disease, in
producing hypertrophy of the ventricle and more forcible
closure of the mitral valves, and thus disease in them. Then
comes tricuspid disease, where the tricuspid is closed under
greater force by an enlarged right heart ; and, lastly, the
pulmonary, bearing the stress of the gorged pulmonic circu-
lation in left-side disease, and then not often found diseased
to any detectible length in life, and still more rarely the sub-
ject of primary disease. It would appear from this that acute
endocarditis is the greatest excitant of chronic endocarditis,
and, next to it, forcible closure of the valves. This is the cause

AFFECTIONS OF THE ENDOCARDIUM. 109

of disease of one valve following disease of the one in front,
and disease of the right side of the heart disease of the left.
We may here review some of the exciting causes of endo-
carditis associated with strain, and this is primarily seated in
the aorta. The two great causes of aortic disease, are gout,
in the aged, or other causes of atheroma, but gout, or per-
haps rather chronic renal disease, certainly first ; and, in the
young, violent efforts, especially such as implicate the whole
muscular system, and are connected with use of the arms.
This last form of aortic valvulitis in young persons, or those
of middle age, is very commonly seen in '' strikers," ham-
mermen, colliers in thin beds of coal, boat racers, gymnasts,
&c. It is extremely common among strikers, and was first
carefully observed in connection with them. These men
have to exert themselves violently during the brief time that
heated iron remains sufficiently hot to be worked. This is
not long, not more than one minute, or one minute and a
half, and during the process of heating the striker is resting,
but, if then examined, he will be found with intense vascular
excitement. This becomes somewhat modified ere the next
call, which is not far distant. This continues for at least ten
hours in each day, and is steadily pursued as an occupation.
None, of course, but strong and powerful men aspire to this
position, and their efforts are stimulated by a natural rivalry.
On examining this form of labour as a cause of aortic valvu-
litis, one peculiarity is observed about it. The labour with the
arms necessitates a fixed position of the muscles of the body
generally to enable the striker to deliver his blows with
precision, and with greater force. This affects the circula-
tion in two ways. 1. The muscles of the body largely cross
the arteries, and, when in action, constricts them and impede
the flow of blood through them ; this action is termed by
AVardrop " the musculo-cardiac function," and he thought it
tended to keep the ventricle full of blood. This it most
unquestionably does, for the ventricle cannot empty itself
completely into the aorta, when the onward progress of the
blood is obstructed by these muscles crossiug them. 2. In
this condition of muscular activity the entrance of the blood
into the muscles is impeded, and thus another great obstacle

110 THE HEART AND ITS DISEASES.

offered to the arterial flow, during this period of general
muscular activity. From these two causes combined the
blood flows slowly into the arterioles of the body, and great
resistance is offered to the flow of blood. This soon brings
out hypertrophy of the left ventricle, and then the blood is
forced into the aorta under greater pressure, while its pro-
gress is hindered, and thus the aorta is excessively distended
and recoils forcibly, driving together the aorta valves under
unwonted pressure. This in time evokes valvulitis, with
its changes. But this obstraction to the flow is not all
the mischief in these cases. While the muscles obstruct the
arterial flow they aid materially in accelerating the venous
flow, contracting as they do in the direction of the trunk.
Thus, while the blood is squeezed out of the muscles by their
action, the blood in the veins is being driven towards the
heart. This leads to its accumulation in the great veins,
which are gorged, they fill the right heart under increased
pressure, while the pulmonary flow is impeded by the diffi-
culty with which the left ventricle disposes of its contents :
then comes hypertrophy of the right side of the heart. The
blood is now driven into the left ventricle under increased
pressure, and dilatation is added to the already existing
hypertrophy ; further hypertrophy is then elicited and a con-
dition of dilatation of the left ventricle with decided hyper-
trophy is established. From this again a larger quantity of
blood is thrown at each systole into the aorta, and a condition
of over-distension of it kept up : this adds further to the
strain and consequent valvulitis.

This is the ordinary history of aortic disease in the
striker, who often complains of palpitation, &c., ere any sign
of valvular mischief can be detected. This muscular in-
ability is in time overcome by hypertrophy, which protects
it, but helps to hasten on the destruction of the aortic valves.
A precisely similar course of events goes on in the collier,
working in thin beds or seams of coal. Here a very con-
strained position is necessitated, which requires for its
maintenance general muscular action, Avhile the collier exerts
himself to the utmost on each *' shift," resting in the mean-
time. Here the same consequences are seen as in strikers.

AFFECTIONS OF THE ENDOOARDroM. Ill

There is also an approach to this in the general muscular
effort demanded from the oarsman in boating, and heart
disease is developed in them frequently, but to a less extent
than in the above cases, because their efforts are confined to
training-times, that is, the very desperate efforts, and are
limited to a few years ordinarily. A similar history is
associated with gymnastic efforts, but commonly the palpita-
tion and other signs of the preliminary stage of muscular
trouble deter from their efforts those with whom it is a
matter of choice, while the striker and the collier must labour
on. This effect of the muscular debility is often very
valuable in inducing the followers of these pursuits to
abandon or modify these efforts, and thus the deleterious
efforts are given up before the latter stage of decided and
marked aortic valvulitis is produced, while in those where
muscular growth is good, this stage of compensatory hyper-
trophy is reached, and mischief inaugurated, which manifests
itself some years after, when its cause is usually forgotten.
That valvulitis should thus hesitate and pause in its progress
is not surprising if the provoking cause be in abeyance, and
often after their University days these violent boating efforts
are given up for a comparatively inactive life in the Church's
service, and then the mischief lingers in its career.

The effect of gout, or, rather, chronic kidney disease,
produces a very similar effect on the aortic valves. The
effect of retained urine salts in the blood has been shown
by Professor Geo. Johnson, Dr. Kelly, and others to consist
in hypertrophy of the muscular tunic of the arterioles.
These contract, and oppose the onward progress of the blood,
hypertrophy of the left ventricle is induced, and, when
induced, the aorta is filled under a stronger ventricle, and
betwixt the hypertrophied ventricle and the hypertrophied
muscular coat of the arterioles the aorta is over distended,
and its recoil closes the aortic valves violently, and aortic
valvulitis ensues. But this subject will be discussed at
length in Chapter XIII. For the further progress of aortic
valvulitis and its consequences the reader must refer to the
Chapter (VII) on valvular lesions.

Thus we see that aortic valvulitis is associated with

112 THE HEART AND ITS DISEASES.

strain, with closure under excessive force, wlien an aorta is
over distended betwixt an hypertrophied left ventricle and
an obstruction offered to the blood current. So, too, mitral
disease may be found along with aortic disease, but usually
not till aortic regurgitation has dilated the heart and pro-
duced great hypertrophy, and thus the mitral valve is closed
under greater pressure. The endocarditis may also spread
from one valve to the other, in addition. Mitral disease
often follows, but rarely precedes aortic regurgitation.

So, too, we see disease of the right side following left
side disease, and rarely otherwise, except when chronic lung
disease opposes the flow through the pulmonic circulation,
and right side enlargement is developed. Thus the pul-
monary valves are rarely found affected, and not so often the
tricuspid, in consequence of the patient's death from the
consequences of venous congestion and impaired circulation.
Still we have enough of evidence to show us that valvular
endocarditis is associated with over-strain of the valves,* and
if additional evidence were required to substantiate this
view it would be found in the endocarditis and thickening-
found in the left auricle when subjected to over-distension in
mitral stenosis ; and in the endarteritis found at points
where the endarterium is stretched and exposed to strain ;
and often found along with aortic valvulitis where the aorta
is continuously over-distended ; and, finally, in the atheroma
in a vein which is over-distended by an artery opening
into it.

Chronic endocarditis may result from other, as yet less
known, conditions, especially in dyscrasial conditions, but
next to acute endocarditis certainly over-strain is the great
provoking cause.

Symptoms. — The symptoms (objective) of chronic endocar-
ditis are nil, nor are the subjective symptoms any more, except
by its effects upon the valves. There is a very limited
njerve supply ; indeed, its existence is rather conjectural than

* This subject is well shown in some cases given by Dr. Clifford Allbutt in
his pamphlet on " The Effects of Overwork and Strain on the Heart and great
Bloodvessels." Reprinted from St. George's Hospital Reports, 1871. Macmillan
and Co.

AFFECTIONS OF THE ENDOCARDIUM. 113

demonstrated in the lining of the heart and blood-vessels,
and affections of them do not give rise to pain, or other
symptom, to indicate their existence.

Prognosis, — The prognosis will depend on the valvulitis
and its consequences, and must be followed out in the chapter
on Valvular Lesions.

Treatme7it, — The treatment resolves itself into a removal
of the exciting cause, where practicable. The abandonment
of severe athletic exercises when an undesirable effect is
being produced on the heart or vessels, and, in those who
must labour, the adoption of some new form of labour not
necessitating these efforts, is desirable. It is of great im-
portance that these causes of endocardial disease and its
terrible consequences be fully recognised. The distance of
the danger, and the entrancing nature of the voluntary
pursuits, make their votaries somewhat inclined to be
sceptical about the consequences, and to attribute the ulti-
mate consequences to some other cause in action in the
interim ; but this is not wise, and the sooner an intelligent
recognition of the consequences of these muscular amuse-
ments now so largely in fashion, the better for those engaged
in them. Physicians' advice has been rejected by them
rather rudely ; but they must remember that we can have no
interest in checking these peculiar sports ; indeed, our
interests lie the other way ; and we probably enjoy the
spectacle afforded as much as other people do.

The more especial treatment must be followed in the
treatment of each lesion, and in the chapter on Treatment.

114 THE HEART AND ITS DISEASES.

CHAPTER VII.

Valvular Diseases— Aortic Obstruction— Aortic Insuf-
ficiency — Combination of — Mitral Obstruction —
Mitral Regurgitation — Combination of — Diseases of
the Pulmonary Valves — Tricuspid Insufficiency.

When then this process of alteration of the tunica intima, so
called atheroma or endarteriitis deformans, has affected the
lining of the aorta and heart, including the surface of the
valves, we find that the morbid process may distort or de-
form the valves so as either to cause them to offer a more or
less decided obstruction to the flow of blood through them, or
to be more or less unequal to prevent its regurgitation, that is,
they become insufficient to fulfil their function. These con-
ditions are commonly enough combined in various degrees,
but usually one or other condition is sufficiently preponderat-
ing to entitle us to call it that disease with the other, for
instance, in aortic disease we may have both forms of disease
united, and we call it aortic obstruction mth regurgitation
where the stenosis preponderates, and aortic insufficiency
with stenosis when the regurgitation preponderates. So,
too, in the pathology and sequelae, whichever preponderates
will be followed by the sequelge more peculiar to it, modified
of course by the amount of the disease combined with the
chief affection. This is equally the case with diseases of the
mitral valve, as regards the diagnosis which is often rather
difficult, and is much aided by the character of the pulse, a
subjective symptom of the greatest value in aiding us to
form a correct diagnosis in valvular diseases of the heart.
There is no doubt some difficulty in learning to distinguish
the different valvular lesions of the heart, and their accom-
panying conditions, but tliis is much magnified by the fears
of the student and want of confidence in his own powers,
and perhaps to some extent by writers not keeping the

VALVULAR DISEASES. 115

students' difficulties sufficiently before their eyes, and com-
piling their book accordingly. A little true thinking over
the necessary origin of certain sounds heard, and the effect
the lesion must have on the parts behind it ; careful examina-
tion of the healthy heart, and of some well marked lesions
in the hospital, and attention to the remarks of his teacher,
will soon enable the student to distinguish a lesion as clearly
as most men; but if the student will attend to tricuspid
lesions, combined murmurs and lesions, &c., before he is in
possession of his alphabet and gets muddled, it is very possi-
ble that he has only himself to blame. But if he learns his
alphabet soundly and learns to spell the simpler words first,
in time will he not only find himself equal to spelling out the
most complex combinations, but will feel a pleasure in his
own power so to do. This power acquired, no diseases admit
of so close diagnosis as heart diseases ; mistakes are undoubt-
edly made, and by the best men, but human nature is fallible
and liable to err from haste or carelessness ; still heart dis-
eases can be disgnosed with a certainty which does not
belong to abdominal diseases for instance.

The time at which a murmur is heard, in relation to the
heart's sounds, its point of maximum intensity, to some ex-
tent its character, the amount of hypertrophy and dilatation,
or either, and its peculiar pulse, are usually sufficient with
intelligent thought to ^x the seat of the lesion, and its
amoimt. In aiding in forming a prognosis and guide to the
development of sequelae and the appropriate treatment, it
may be well to insist on three divisions. When the aortic
orifice alone is affected, and the mitral remains perfect, we
have little or none of the subjective symptoms due to obstruc-
tion of the circulation ; when the mitral is involved, we have
lung symptoms, or rather chest symptoms necessarily evoked ;
when the pressure of obstruction is affecting the right heart,
and producing decided dilatation, and still more if the tri-
cuspid is involved, we have general venous stagnation and
its consequences.

Aortic Obstruction. — The first disease then under the first
of these three divisions is aortic obstruction or stenosis.
This is not an ujicommon form of heart affection, especially

I 2

116 THE HEART AND ITS DISEASES.

in advanced life, and is usually well marked, but not uncom-
monly associated with more or less regurgitation. It is
always found with, hypertrophy, because the ventricle is not
filled under undue pressure, the great cause of dilatation ;
its pulse is characteristic.

The pathological changes which give rise to obstruc-
tion at the aortic orifice at least, are invariably the result
of endarteriitis deformans, or atheroma. At first the valves
are somewhat thickened and rigid, and fold back^vard
when the blood column is driven through them on the ven-
tricular systole. This produces a sawing murmur, which is
systolic. The valves become more rigid and thickened,
opaque and contracted, often atheromatous vegetations
spring from them and almost close the orifice entirely. The
extent to which this goes on is often simply surprising, and
life has been maintained until a bristle could scarcely be
passed through this opening. This obstruction necessarily
is accompanied, or rather followed, by changes in the muscu-
lar walls of the heart. This is invariably hypertrophy, and
usually of the purest kind. The obstruction is not one which
comes on suddenly, but rather in the most gradual manner,
and consequently there is no primary formation of dilatation,
as happens when the obstruction offered is rapid in its for-
mation. Simple hypertrophy is the muscular condition asso-
ciated with this lesion. This affection is not commonly
associated with other valvular lesions, and is not usually
accompanied by the general symptoms of heart failure until
a very advanced condition of stenosis, or of fatty degenera-
tion of the walls is reached. This last is almost sure, sooner
or later, to follow from imperfect filling of the aorta, and sub-
sequent imperfect circulation in the coronary vessels. The
affection is essentially chronic in its character. It is, too,
most commonly found in advanced life, so that it contrasts
with the frequency of mitral disease in the young. It is,
indeed, a disease of middle and advanced life, and is essen-
tially associated with the atlieromatous process.

Diagnosis, — On inspection and palpation nothing is to be
discovered more than a distinct pulsation at or below the
sixth rib, regular, defined, and powerful. There is in fact true

VALVULAR DISEASES. 117

hypertrophy of the left ventricle ; rarely, or never, mixed with
dilatation unless there be also regurgitation, or the hyper-
trophy is undergoing degeneration. Percussion, too, shows
an increase of dulness over the left apex and below, corre-
sponding to the apex beat. Auscultation is the great means
by which we distinguish positively the existence of aortic
obstruction. Firstly, in connection with the signs furnished
by percussion, palpation, &c., we find the loud but muffled
first sound of hypertrophy ; while the blow on the chest-wall
is distinctly communicated by the stethoscope. Then we
find also a sound of a sawing character, an obstructive
murmur accompanying and often masking, more or less com-
pletely, the first sound. This sound is heard with maximum
intensity over the second right costo-sternal articulation, it
can be followed up the aorta, along the carotids and sub-
clavians, and even further. It is a comparatively loud
murmur, and is heard over a large area, over the base of the
heart, at the left apex, and at the ensiform cartilage. It thus
simulates mitral and tricuspid regurgitation, and all murmurs
heard with the first sound must be tracked to their point of
maximum intensity. Without this many murmurs will be
hastily set down as mitral or tricuspid, from the clearness
with which they are heard over their areas, unless they be
followed out.

The objective symptoms are as marked as the physical
signs. The action of the hypertrophied heart with aortic
stenosis is regular, usually slow, and rarely palpitating.
There is the peculiar heaving, steady, character of pure
hypertrophy. After severe exertion, or exhaustion, there is a
tendency to intermit. The exhausted ventricle is taking a
longer rest before it can meet that obstacle offered to the
forward progress of the blood column. This halt is some-
times very prolonged. Consequently, aortic obstruction is
one of the forms of heart disease associated with sudden
death. That halt may be permanent. Aortic stenosis is
thus liable to sudden death ; while it is also more free from
the subjective symptoms and consequences of obstructive
circulation.

The pulse of aortic obstruction is small, on account of

118 THE HEART AND ITS DISEASES.

the obstrTiction at the aortic orifice, hard and sustained from
the hypertrophy. The pulse is hard, incompressible, and
sustained, while it is small, and thin or wiry. It is not unlike
the pulse characteristic of abdominal inflammation.

Aortic obstruction is liable to be confounded with some
other affections,, from the time and position of its murmur.
In time it corresponds with mitral regurgitation. In time
and position with aortic dilatation and aneurism of the
ascending aorta. It would, perhaps, be more correct to say
that these diseases are apt to be mistaken for aortic obstruc-
tion : and they will be considered as regards their diagnosis,
&c., in the chapter on Diseases of the Great Vessels (Chap-
ter XLY),

In time and position this murmur is exactly simulated
by the anoemic bruit. In many conditions of anoemia, and
especially in chlorosis, a murmur is heard in the heart exactly
corresponding to aortic stenosis. The blood deficient in
quantity, or depraved in quality (spanoemia), furnishes m its
passage through the aortic orifice murmurs from vibrations
in the semi-lunar valves.

The differences are, in anoemic bruit, first youth and sex,
being usually in girls, the positive evidences of anoemia and
debility, and a weak, short, compressible pulse ; and wanting
the characters of aortic obstruction, as hypertrophy and its
signs and symptoms, and the sustained and compressible
pulse; the murmur, too, is not communicated into the dis-
tant arteries, though in the neck it is simulated by the bruit
de diable, the vibrations in the jugular valves ; this can be
arrested by pressure of the finger ; the aortic murmur cannot
be so arrested in the carotids.

From mitral regurgitation it may be distinguished by a
variety of measures, as the position of maximum intensity,
the conduction of the sound, the absence or presence of lung
symptoms, &c., liypertrophy, as compared to hypertrophy
with dilatation, and finally by the character of the pulse.

VALVULAR DISEASES. 119

Characters special to Aortic Ohstruc-
tion.

Systolic, but heard with mnximum
intensity at second right costo-sternal
articulation, and communicated along
the arteries.

Rarely connected with lung symp-
toms.

No accentuation of pulmonary second
sound.

Pure and simple hypertrophy of left
ventricle and well defined apex ; beat
usually powerful.

Pulse hard, firm, wiry, and sustained ;
regular, and when not so regular in
time, arrested or intermittent.

Tendency to sudden death, and
absence of consecutive complications.

Characters special to Mitral Regurgi-
tation.

Systolic, but heard with maximum
intensity at left apex, and in a hne
passing behind the nipple, or over the
left auricle.

Intimately connected with lung
symptoms.

Accentuation of pulmonary second
sound.

Mixed hypertrophy and dilatation ;
apex beat diffused, and not so marked
in power.

Pulse irregular in volume, more or
less blood always escaping through the
mitral valve. Not sustained or incom-
pressible.

Tendency to linger on, with consecu-
tive complications.

These points are sufficient to enable a diagnosis to be
made betAvixt aortic obstruction and mitral regurgitation.

The aortic obstructive murmur is often simulated, too, in
fevers by the altered blood, but this is not likely to lead to
any mistake ; it is sufficient to merely mention it.

Prognosis. — The prognosis of aortic obstruction in the
early stages, and when not very marked, is not bad as to
dm^ation of Hfe : as to recovery, like all valvular lesions, it is
hopeless. The condition of the muscular walls must form
the foundation of prognosis, and when the ventricular systole
becomes feeble, and more so if the feebleness be indicated
by intermittency, the prognosis is becoming very bad. It is
not a form of valvular disease commonly followed by dropsy
and other consecutive changes, but, on the other hand, it is
somewhat liable to genuine apoplexy, especially when com-
bined with morbus Brightii. There is a decided risk of
sudden death, especially if that ventricular chamber should
be over-distended with that narrowed orifice in front, the
over-distended ventricle may be unequal to the effort, and
remain permanently in diastole. It is found associated with
cerebral anoemia, especially in fatigue, and when the heart is
exhausted: the prolonged halt, by cutting off the arterial
blood supply to the cerebrum, may cause the patient to fall
from cerebral anoemia. In one case that was remarkably
well seen; and treatment of the heart effectually relieved
the head symptoms.

120 THE HEART AND ITS DISEASES.

Treatment.' — The treatment of aortic obstruction is ac-
cording to the rules laid down in the chapter on Treatment.
Just one point must be alluded to. Much has been said and
written on the subject of digitalis, slowing the heart's action,
and allowing more time for the blood to flow through the
narrowed orifice. This is erroneous ; it is not a question of
time ; that would not alter matters ; it is a question of in-
creasing the driving powder, the only means by which an
equal bulk of blood can be driven through a narrowed orifice
in equal time.

Aortic Regurgitation. — The next affection of the aortic
valves is insufficiency. It is allied to aortic regurgitation
both in situation, in causation (pathological), and in its
freedom from the systemic consequences of venous conges-
tion, until the mitral orifice becomes affected. This last is,
however, more common in aortic regurgitation than in ob-
struction, as more causes are in action than the mere spread-
ing by contiguity of atheroma from the aortic orifice to the
mitral valve of the fixed wall or septum.

In aortic regurgitation the atheroixiatous process has
rather contracted the semi-lunar valves than converted them
into rigidity. In slight affection of this form of lesion we
find the free edge of the valve thickened, cord-like, and con-
tracted. In other cases the process has had rather an
ulcerative tendency, and one side of a valve has given way.
In other cases a violent effort has been known to tear down
these valves. In fact, aortic regurgitation is essentially con-
nected with effort. In the iron districts of England this form
of disease is unusually frequent, especially among *' hammer
men" or "strikers"; but it is also found among colliers,
and more so when there are thin seams of coal, and the
collier has to work in constrained positions. It has been ob-
served to be associated with labour involving great use of
the arms, a fact not only curious but instructive in relation
to tlie pathology of tliis affection. For tlie exciting cause of
the low interstitial inflammation, with growth of connective
tissue, is essentially the violence with which these valves are
closed, or rather driven together by the backward rush of
blood on the aortic recoil. When, then, recoil is increased,

VALVULAR DISEASES. 121

SO is the force with which these valves are closed. This is
well seen in the condition of these strikers immediately after
a " heat." He is panting with hurried respiration and excited
action of the heart and pulse. During his brief exertion his
muscles have been in violent action, and many of them cross
the arteries, as Wardrop has pointed out (his musculo-cardiac
function), and thus oppose the onward flow of blood. His
chest is fixed in order to furnish fixed points from wdiich the
muscles work, and the whole frame is in a posture to enable
him to deliver his blows with greater precision and force.
We have then the muscles crossing the arteries and obstruct-
ing the flow of arterial blood, while their action is decidedly
to propel the venous blood towards the heart. This tends
to fill the great blood centres, and a partial hypertrophy
of the heart commences. The ventricle, too, filled under
greater pressure from the gorged pulmonic veins, is of full
capacity, so that we find a strong and large ventricle with a
large chamber acting against the obstruction offered. Even
previous to the formation of aortic valvular disease, these
men have often heart symptoms as palpitation, &c., showing
that the ventricle is taxed. In time the hypertrophy is dis-
tinct. Thus we have a powerful heart opposed to the ob-
struction offered, and consequently great aortic tension, and
the valves are closed violently. In considering the connec-
tion of this lesion with the use of the arms, we must bear in
mind this point. When the labour is in the arms, the body
must be kept in a certain fixed posture, and this entails
general muscular rigidity. Almost all the muscles of the
body are brought to bear on the maintenance of this postural
attitude. Consequently, these rigid muscles offer an obstruc-
tion to the entrance of the blood into them, and thus a great
obstacle is furnished to the arterial blood stream. This con-
dition of general muscular action is not found in other forms
of labour, and supplies us with the explanation of the con-
nection of the form of valve lesion with labour entailing
great use of the arms. Sooner or later this leads to such an
amount of disease in the aortic valves, as to render them in-
sufficient, and at the same time often a dilated and somewhat
rigid aorta itself

122 THE HEART AND ITS DISEASES.

In connection with this explanation of the oetiology of
aortic regurgitation, maybe adduced some statistics collected
by Bamberger. In 50 cases of aortic insufficiency, Bam-
berger found 38 men and only 12 Avomen ; though women
do much of the coarser kind of labour in Vienna. Of these
50 cases 15 were under 30 years of age.

It is not meant from this that aortic regurgitant disease
always takes its rise in excessive bodily exertion, but merely
that that is a common cause : it is also connected with
Bright's disease, endarteriitis deformans^ and endocarditis.

When, however, the blood has once commenced to flow
backwards through the aortic orifice, a new series of changes
are at once instituted. The bulk of blood driven back by
the poAverful aortic recoil is added to that normally coming
in from the pulmonic system through the mitral valve. By
the combination of these two streams, the left ventricle is
distended in its diastole by an increased bulk of blood driven
in under increased pressure. The result of this, as shown in
a previous chapter^ is to dilate the heart, and hypertrophy is
rapidly developed to resist this excessive distension. This
goes on to a remarkable extent, and the heart becomes both
dilated and hypertrophied to unusual dimensions the cor-
bovinum. It may even reach down to the eighth intercostal
space. This excessive hypertrophy with dilatation causes
an unusual bulk of blood under violent pressure to be forced
into the aorta and arterial system generally. This in its
turn becomes distended and dilated, and in a little time
atheromatous. This violent distension can be felt even in
the anterior tibialat, the ankle, and has been seen by the
ophthalmoscope in the arteria centralis retina). But this ex-
cessive distension is brief in its duration, and the blood
escaping backwards at the recoil, it is cut short as it were.
This is well shown in a sphygmograph tracing. The sensa-
tion to the finger is that of " balls of blood shot under the
finger," a most characteristic expression. The disease pro-
ceeds in every direction, the aortic orifice becoming more in-
sufficient, the aorta thickened, and the backward rush of
blood both greater in bulk and driven back more violently,
BO the heart's chamber becomes more dilated and more

VALVULAR DISEASES. 123

hypertropliiecl. This in its turn forces a larger mass of blood
at each systole violently into the arteries, the vessels from
this excessive distension become atheromatous. In the
meantime this arterial distension gives the patient headache,
vertigo, &c., bleeding at the nose, and when their structural
integrity is impaired, the arteries of the brain are liable to
rupture, and true apoplexy to happen. This result of in-
creased arterial pressure is quite different from the apoplexy
produced by impeded venous flow in consequence of heart
failure. It is the direct consequence of dilatation and hyper-
trophy not connected with, and therefore not neutralised by,
obstructed blood flow. The distension causes, too, pulsation
of the abdominal aorta, in females menstrual disorders and
increased loss of blood at each menstrual period, and even,
according to Oppolzer, albuminuria from increased tension
in the renal artery.

But this condition is not permanent, and the excessive
hypertrophy does not persist. This has been most inge-
niously pointed out by Mauriac. He has shown that the
cardiac nutrition supplied by the coronary arteries is soon
involved. The aortic recoil is the propelling power into the
coronary circulation, and when this is no longer arrested in
the backward direction by the aortic valves the flow into the
coronary vessels is diminished. So we find that this hyper-
trophy is not long in undergoing tissue- degeneration. This
is aided, too, by the fact that the atheromatous aorta and large
vessels lose their elasticity, and do not recoil so perfectly.
These combined causes soon affect the structural integrity of
the heart walls, and the heart is less equal to resist the dis-
tension. It again yields, and dilatation recommences, hyper-
trophy to restrain it being no longer possible. The patient
rapidly sinks, but as long as the mitral valve is unimpaired,
there are not the symptoms of obstructed venous circulation.
But the patient gets feebler, his pulse becomes hesitating,
intermits, and finally ceases in diastole. Not uncommonly
the mitral does become affected, and that by various means.
The most common one is the extension of the atheromatous
process from the aortic valves along that small sheet-like
portion of endocardium which stretches from the base of the

124 THE HEART AND ITS DISEASES.

aortic semilunar valves downwards, and forms the valve of
the fixed wall of the mitral orifice.

The great dilatation of the chamber, too, may lead to the
valves becoming incompetent, but, as Rokitansky shows, the
valves and musculi papillaries ordinarily stretch with it, and
so no insufficiency arises. But under these circumstances of
excessive action of the ventricle, the valves and musculi
papillaries, with their tendinous cords, are apt to become
structurally modified, and this greatly encourages the exten-
sion of the mischief from the aortic orifice to the mitral
valve. This involves the tendinous cords, and they become
shrivelled and the valve imperfect. Traube has advanced
a theory that the miti'al valve becomes incompetent from
atrophy of the musculi papillaries. This is produced in this
way : the rush of blood backwards through the aorta puts
the valve of the mitral of the fixed wall on the stretch during
the diastole, when it should also rest along with the other
muscular structures. During systole it is of course on the
stretch, and this incessant action both deprives the musculi
papillaries of their due rest and also of their nutrition. They
atrophy, become incompetent, and the valve, no longer
sufficiently restrained by them on systole, is washed back by
the powerful ventricle. Thus, by one or other actions, the
mitral valve often becomes involved in aortic regurgitation.
When this occurs, the symptoms especial to aortic disease
become modified by those symptoms of mitral failure and
its sequela3, which will be more especially considered in that
section.

The diagnosis of aortic regurgitation presents no great
difficulties, and the points of it are such as might be
expected from its pathology. The signs are as following : —
On inspection, a distinct pulsation over the cardiac region is
observed, and on palpation a distinct and powerful thud is
felt over a considerable area. On percussion, a wide area of
dulness is found extending to the left, and below the normal
area. It is not so pointed as in simple hypertrophy of the
left side, but is more globular, and presents the characters
given before as belonging to a combination of hypertrophy
and dilatation. This is quite in agreement with what pal-

VALVULAR DISEASES. 125

pation reveals, and percussion and palpation both aid
in demonstrating a- large, strong, but also widened left
ventricle.

But auscultation tells us most of what changes have gone
on. The first sound is loud, prolonged, but masked often
by a systolic murmur caused by the rush of blood over the
roughened aortic orifice. This murmur may be heard up the
aorta. There may, too, be heard a soft regurgitant sound at
or behind the left nipple, but soon lost. It may be distin-
guished from the aortic murmur and localised. But the
characteristic murmur of aortic regurgitation takes the place
of the aortic second sound. Its time singles it out ; for the
pulmonary valves never almost become insufiicient. The pul-
monary second sound may be found at its point of maximum
intensity, bat only with care, for the murmur produced by
the backward rush of blood through the aortic orifice is clear
and distinct. This murmur is most clearly heard at the base
of the heart, and where the current takes it with it to the
apex. Not unfrequently it is very distinct at the base of the
ensiform cartilage. Wherever heard, it is always true to its
time of being heard during the second sound. It is truly
diastolic. When combined with obstruction, which is very
common, there is a very distinct "see-saw," or rather " saw-
see " sound heard over a large area. It may be heard so
clearly at the mitral area as to give the impression that it
must be produced here, until examination over its more
proper area reveals it to be even louder there. The vibra-
tions, too, which to the ear are sounds and a murmur, are
apparent to the finger when placed over the base of the
heart. The ear when applied, with or without the stetho-
scope, becomes conscious of the powerful heart stroke which
accompanies this condition.

These signs in the heart are aided by signs in the arteries.
The aorta, dilated, atheromatous, and roughened, can often
be felt at the sternal notch, especially when the patient
holds his head forward, and the vibrations can be felt with
the finger. The rapid and excessive distension of the
arterial system can be felt in the anterior tibial, where the
Germans always feel for it. All parts of the arterial system

126 THE HEART AND ITS DISEASES.

are affected, down to the smallest arteiy, as has been stated
before. This arterial distension may be felt as a distinct jar
over the Avhole body, and Sir Thomas Watson relates a
case of a man whose w^ife would no longer take his arm
wdien walking out wath him, in consequence of the unpleasant
blow-like sensation produced by the arterial pulsation.

The symptoms are not peculiar for a long time, and a
man may continue to labour for some time after the establish-
ment of distinct aortic regurgitation. But he sooner or later,
and usually sooner, has to relinquish his employment ; and
in the iron districts there are numerous young men so in-
capacitated. He is anxious, nervous, terribly conscious of
the working of that heart. The carotids pulsate very visibly,
and are characteristic when seen on each side of an anxious,
wistful, and somewhat frightened looking face. A little later
he is in bed, propped up, breathing with difficulty, his irregular
pulse telling of fatty degeneration gradually enfeebling
his heart. Often a process of skin-degeneration, not un-
commonly quite fatty, and unctuous to the feel and visible
to the eye, is found along with this form of heart disease.
The degenerate atheromatous temporal artery may be
observed plainly jerking. The appetite fails, a sort of semi-
unconsciousness grows over him, and soon the last change
follows.

The prognosis of aortic regurgitation is not very difficult,
unfortunately. It is a form of heart disease which tends to
prove fatal very rapidly. The hypertrophy becomes exces-
sive to resist further dilatation from the increased pressure
of the distending force ; the large and powerful chamber in its
turn induces changes quickly in the arterial system, while the
law of Mauriac ensures speedy degeneration. The patient
in the meantime is liable to genuine apoplexy, though this
does not occur very frequently, and he is also very liable to
be carried off by intercurrent disease. The prognosis is much
affected by the amount of obstruction combined with it ; and
in the very common cases of this combination the more it
partakes of the character of obstruction, and the less of that
of pure insufficiency, the better for the patient, and the longer
is he likely to live. With care in some cases life may be

VALVULAR DISEASES. 127

prolonged for a considerable time, but only when combined
with inaction.

This brings us very naturally to the question of treat-
ment. And though it has seemed best, for divers reasons, to
aggregate the treatment in one chapter, as it can only be
regarded as built on the same plan in every form of heart
failui'e, still there are some pomts of special moment in the
treatment of aortic regurgitation. The first is to at once
insist on the abandonment of all severe labour, and the
adoption of some light and more constant occupation. As
this disease is so often found in working men, this is a pain-
ful point to press steadily and urgently. But it must be
done, and the reasons given for it. By reducing the calls on
the heart, we can to some extent preserve it ; permit labour
as long as it can be sustained, and you anticipate that epoch.
To attempt to lower that heart's action would be to at once
invite dilatation to proceed. The force of the ventricular
action, and the increase in the amount or bulk of blood dis-
charged into the arteries at each systole, are rapidly and
inevitably ruining those arteries ; but it is unavoidable, and is
the lesser evil of the two, for it is when that force is beginning
to fail that we see the beginning of the end. The recognition
of the inroad of this disease in its earliest stages is of the
utmost importance, and its etiology is of great moment as
giving us data as to when we may suspect its approach, and
then we might take measures to delay its advent. After its
establishment, each case mil present indications of its own,
which will be patent enough, and must be treated accordingly;
but all treatment is unsatisfactory. At times some relief may
be afforded, but usually and generally the treatment is merely
palliative, and the profession unite in regarding aortic regur-
gitation as one of the most serious and, withal, intractable
forms of heart disease. The treatment must be conducted
according to the rules laid down in the chapter on Treatment,
with such modifications as the good sense and intelligence of
the reader deem necessary.

Mitral Disease. — In regarding the pathology of disease of
the mitral valve, it would serve no useful end, and lead merely
to confusion, to separate insufficiency and stenosis. The mitral

128 THE HEART AND ITS DISEASES.

valve has already been shown to be involved hi some cases
of aortic regurgitation. It is often primarily affected, and
especially in endocarditis associated with acute rheumatism.
Here the destructive process often affects the chordae tendinese,
till the valve becomes attached to the musculi papillaries
themselves ; the process commonly creeps along the edges of
the valves, and gradually draws the two valves together,
until the mitral valve is a rigid cone protruding into the left
ventricle, with a narrow, slit-like orifice, commonly called a
"button-hole" mitral. This cone is attached immediately
to the musculi papillaries, while the endarteriitis creeps over
their surfaces in time and distorts them. At other times the
process confines itself to gradually thickening and contracting
the valve itself, and especially the one which lies near the
aorta. Here insufficiency is produced, and not stenosis. In
other cases, but perhaps less seldom, the valve, more par-
ticularly connected with the outer wall of the ventricle,
becomes diseased, and either contracted, or allowed to wash
backwards on the systole, from ulceration of the chordas
tendineee, e^c. The various forms of mitral disease are
common, both insufficiency and stenosis, and that midway
form combining both. The mitral valve, too, is especially
affected in those cases of heart disease occurring in young
persons, and connected with acute rheumatism ; while, on the
contrary, aortic disease is rather connected Avith general
atheroma of the arteries in older or elderly people. In mitral
disease we come to a series of backward actions, which are
not associated with simple aortic disease, but Avhicli inva-
riably manifest themselves when the mitral valve is affected,
whether primarily or secondarily.

The changes involved by mitral disease affect, first, the
vessels of the pulmonic circulation and their terminations at
each end. Tlius the left auricle is enlarged and thickened,
and where there is stenosis, not unfrequently rigid, not col-
lapsing when cut, and with its lining membrane white,
opaque, and atheromatous. The pressure to wliich it is sub-
jected alters it materially, and in time it may undergo de-
generation. The vessels behind are firstly distended and
thickened, and this extends to the pulmonary artery, which

VALVULAR DISEASES. 129

may become as large and thick as the aorta. This is accom-
panied by a dilated and thickened right ventricle which
forces blood into the pulmonic system under increased
pressure. This is most readily detected by the increased sound
produced at the semilunar valves. Skoda first pointed out
the importance of this accentuation of the pulmonary second
sound in mitral disease. This increased tension in the pul-
monary circulation leads in time to changes in the thickened
vessels. They become rigid and atheromatous, and even in
time the subject of fatty degeneration. But this condition
of congestion of the pulmonic system leads to many second-
ary changes in the lungs and air tubes. The nutrition of
the lungs is not altogether derived from the bronchial
arteries, but is largely supplied by the pulmonary circulation,
and a plug in a pulmonary vessel will lead to necrosis of that
part of the lung to which it is distributed. So we find
increase of connective tissue, leading to atrophy of the lungs
and deposits of pigment, especially in young people. We
find rupture into the substance of the lung and true pul-
monary apoplexy, the clots being round and firm, and not
unlike a black bagatelle ball. In older persons, where there
is often allied kidney disease and the blood is impure, we
have often a deteriorated lung tissue, friable and liable to
the formation of emphysema in the repeated paroxysms of
dyspnoea which occur. The establishment of emphysema
adds to the difficulty of breathing already existing.

The congestion, too, is felt in the bronchial lining mem-
brane and an increased flow of bronchial mucus is usually
present, and is called chronic bronchitis, or if profuse, bron-
chorrhoea. This bronchial flow adds to the patient's distress
and often prevents refreshing sleep. Whether it arises from
congestion of the pulmonary vessels or true bronchial veins
is not of much importance. This pressure on the vessels
may lead to passive haemorrhage, which is often useful as
giving relief. As we cannot always discriminate betwixt
this haemorrhage and flow from a rupture in an atheromatous
pulmonic vessel, our prognosis must be guarded. There is
often oedema of the lungs, especially in the latter stages,
and, finally, pleuritic effusion, and, along with the latter,

K

130 THE HEART AND ITS DISEASES.

effusion into the pericardial sac. What changes take place
behind the tricuspid must be considered when tricuspid lesion
is under consideration ; at present we are dealing with the
immediate consequences of mitral disease itself. The symp-
toms produced by these lung changes, &c., are what might
be expected, difficulty in breathing, especially on slight
exertion, cough, expectoration, and, not uncommonly, hae-
moptysis. There are some points of peculiarity about the
cough of pulmonic congestion which need pointing out.
This cough is commonly found along with heart disease, both
in old and young, but is uever absent from young victims to
mitral disease. It is a dry, imperfect kind of cough, and
much resembles a nervous cough, and is quite distinct from
the cough which raises phlegm. It is somewhat difficult to
describe, but is not at all difficult to recognize after being
once observed. It is often a source of considerable annoy-
ance, and tempts the patient to try cough medicines, which
often do great harm, especially as the indications seem to
point to paregoric, or other medicaments containing opium.
It is only to be treated by measures which affect the con-
dition on which it depends.

At the same time, caution must be exercised in dis-
criminating betwixt the increased flow of bronchial mucus
from a passing condition of excessive pulmonic engorgement
and an attack of acute bronchitis. This latter is almost
invariably fatal when it occurs in a person with chronic
mitral disease, the former often threatens life gravely, but is
commonly enough recovered from. Mere flow from conges-
tion lacks the signs and symptoms connected with the income
of an inflammatory attack. These symptoms are all common
to mitral disease, whether insufficiency or stenosis. But it
is of great matter to form a correct diagnosis, especially as
regards prognosis.

Mitral Obstruction. — We will take first mitral obstruction
according to our order. Mitral obstruction, depending as it
does on obstruction existing betwixt the left auricle and
ventricle, has a murmur, often a distinct one, found imme-
diately before the ventricular systole. It is pre-systolic, and
not diastolic as described in older works. This makes it

VALVULAR DISEASES. 131

peculiar and special, for though I have read two cases, one
by Bamberger and the other by W. T. Gairdner, which were
deemed obstructed tricuspid, both turned out to be caused by
tumours pressing on the right auricle. Tricuspid obstruction
is as yet unknown."^

We have, then, a murmur heard at the tricuspid point of
maximum intensity in the fourth intercostal space about an
inch in front of the nipple, which is pre-systolic. It is accom-
panied by chest symptoms, by accentuation of the pulmonary
second sound, and right side enlargement. There is no
increase in the size of the left ventricle, and the pulse is
small, compressible, but regular — quite regular. It is com-
monly found in the young after rheumatic fever, and its
prognosis is bad, in consequence of the gradual progress of
the pathological changes on which it depends, and the im-
possibility of compensatory changes being long effective.

In mitral regurgitation we have some points of important
difference from mitral stenosis. The sound or murmur is
heard not only from this point in the fourth intercostal space
in front of the nipple, but is heard even sometimes away
behind the nipple as well, and even in some cases reaches its
maximum intensity about an inch, or even more, behind the
left nipple. In some cases the murmur is confined to these
areas, in other cases it can be heard all over the back. The
sound is systolic, and may therefore be confounded with
aortic obstruction, the points of distinction having been
already given. It is invariably accompanied by dilatation
and more or less hypertrophy in the left ventricle, as well as
the changes in the right side common to all mitral disease.
The changes in the left ventricle, as Niemeyer shows, are
due to the distension of the flaccid chamber by blood driven
in under unusual pressure. At each ventricular systole so
much blood is driven backwards through the incompetent
mitral ; this bulk of blood is added to tliat already in the
distended pulmonic system, driven in by a thickened right
heart. Consequently, when the blood again rushes into the
flaccid chamber, it does so under greater pressure, and con-
sequently we have dilatation with more or less hypertrophy.

* Except •when congenital.

K 2

132

THE HEART AND ITS DISEASES.

Another point about mitral regurgitation is its peculiar
pulse. This pulse will itself often form a sufficient ground
for a diagnosis to a competent finger. It is obvious that
whatever bulk of blood passes backward on each systole, so
much less will pass forward into the aorta and arterial system.
Why this should be more at one time than another, it is im-
possible to say. This difference is felt in the radial pulse,
and constitutes uTegularity in volume. That is its pecu-
liarity, its variableness in volume. This is quite distinct
from irregularity in time, even when they are found together,
as is common enough in the later stages of the disease.
Mitral regurgitation is rather a disease of advanced life, and
often permits of a good prognosis as to time.

#•

Mitral Obstruction.
Murmur limited, and pre-systolic.

Never accompanied by changes in left
ventricle.

Pulse small and regular in bulk and
time.

Found commonly in young subjects.
Found alone as regards left side of
heart.

Prognosis as to time very bad.

Mitral 'Regurgitation.

Murmm* not limited, often heard
backwards, and systpHc.

Always accompanied by more or less
change in left ventricle.

Pulse irregular in volume, varying
much, and often in bulk, and in the
latter stages in time.

Found in young subjects, but equally
in old persons. Often found in con-
nection with aortic disease.

Prognosis as to time often very fair.

Frequency of accompanying tricuspid
disease.

Changes in right heart invariable.

Accentuation of second pulmonary
sound.

Cough and other chest symptoms.

Prognosis as to life bad.

Points common to each.

Frequency of tricuspid disease.

Changes in right heart invariable.
Accentuation of second pulmonary
sound.

Cough and other chest symptoms.
Prognosis as to hfe bad.

This chart points out the points of resemblance and of
difference. Often, however, are found cases presenting more
or less of points special to each. These mixed cases, as in
aortic disease, must be classed according to the one they
resemble most, with the other added as a qualification. The
prognosis, too, will go with the form which it most resembles.
As the difference in prognosis has been inserted in the chart,
it may be desirable to give the grounds for it.

Prognosis. — The prognosis in mitral disease is founded on
the pathological changes. Thus in stenosis the .process of

1

VALVULAR DISEASES. 133

matting the valves and chordae tendinese together, admitKS of
no compensation ; and the obstruction thus offered soon ruins
all parts behind the lesion. The progress of the case thus
is more rapid. But in mitral regurgitation the lesion is often
slow in its growth and confined to the valve on the aortic
side. As this becomes shrivelled and smaller, the general
dilatation of the ventricle has affected the outside wall and
its valve, lengthening and elongating the musculi papillaries
and chordae tendineae. Thus the valve of the yielding wall
is still stretching across a great part of the orifice, while the
pressure of the blood behind aids somewhat in preventing
regurgitation. Taking the whole circumstances together,
mitral stenosis is a disease whose tendency is to pass rapidly
from bad to worse, and is soon fatal, whereas mitral regurgi-
tation has more tendency to remain in statu quo^ advances
slowly, and admits of some, though imperfect, compensa-
tion.

Treatment— l^YiQYQ are no particular points to be attended
to in the treatment of mitral lesions. The treatment must
be conducted on the general principles. Digitalis can give
only temporary and fleeting relief in mitral stenosis. In
mitral regurgitation, it often strengthens the right heart and
enables the left ventricle to resist the increased distension,
and is often of great and lasting service.

Diseases of the Right Side of the Heart. — We now come to
diseases of the right side of the heart, when we have a totally
new series of phenomena added to those already described :
when the disease of the right side is secondary to disease of
the left side, that is in the great majority of instances, and
almost invariably as regards changes in the valves. Even
as secondary affections, diseases of the pulmonary orifice do
not furnish us with much to describe as regards pathology,
while the diagnosis is most difficult.

Diseases of the Pulmonary Orifice, — If diseases of the pul-
monary orifice were not so infrequent, we might perhaps
know something more about them. As it is, we know that
the pulmonary orifice may become affected secondarily to
disease of the aortic orifice, that this may entail either sten-
osis or insufficiency, or that the pulmonary valves may

134 THE HEART AND ITS DISEASES.

become affected by the extreme tension in the puhnonic cir-
culation in disease of the mitral valve.

Still it is rare to find the pulmonary valves affected even
in great obstruction to the pulmonic flow, and a small festoon-
looking deposit of atheroma in the valves is not even usual.
The pulmonic orifice is occasionally narrowed by congenital
stenosis at the conus anteriosus, but this belongs to another
chapter.

As to the diagnosis of pulmonary lesions, it is arrived at
by exclusion (ihiefly. The positive points being sensible
superficiality in the sounds, absence of all sound at the
back, and entire absence of disease of the left side of the
heart. More than this it is scarcely safe to say, except that
the pulse at the wrist would not have the peculiarities im-
printed on it which would be found were the disease at the
aorta. As to the time at which they would be heard, &c.
Pulmonary stenosis has a feeble sound discernible over the
third left costo-sternal articulation, limited in its area, not
heard in maximum intensity at the aortic area, the second
right costo-sternal articulation, and, of chief moment, not
communicated along the aorta and great vessels. There is
evidence of right side hypertrophy and absence of left side
hypertrophy.

So, too, in the almost unknown cases of pulmonary regur-
gitation, the diagnosis was established by the foregoing rules
for exclusion, and by the absence of that pulse so peculiar to
aortic regurgitation. But the establishment of a diagnosis
of pulmonary disease is a difficult task for the most accom-
plished auscultator, and can scarcely be expected from the
majority of those for whom these pages are specially intended.
Not that they should not try, but that they must not feel
chagrined if they are not quite successful in avoiding error.

•The prognosis of pulmonary disease is essentially bad,
and its addition to left side disease hastens the end of the
case. Also when occurring primarily it may be fairly pre-
sumed that its effect on the right ventricle is to produce in
it and in the tricuspid valve, those changes which close the
scene of left side disease, when the right side has become
implicated.

VALVULAR DISEASES. 135

The comparative frequency of disease in the right and
left sides of tiie heart in intra-nterine life is reversed : then
disease of the right side is much more frequent, and disease
of the left side almost unknown.

Tricusjnd Disease. — The extreme rarity of stenosis of the
tricuspid valve, if indeed it ever exist, has not enabled us to
give any positively observed data for it ; but it is not diffi-
cult to see that a pre-systolic murmur at the base of the
ensiform cartilage would be its chief sign, and that general
venous congestion would follow it, and that too to a marked
extent. On these data a diagnosis has been formed, but in
the only two cases which I have seen reported, in each case a
tumour pressing on the auricle has been found to have occa-
sioned the murmur and the symptoms. Under these circum-
stances there is nothing to say as to how a diagnosis should
be established. This is of less moment, as it is extremely
unlikely that the reader will ever be called upon to make one.

But regurgitation through the tricuspid is not at all an
uncommon form of valvular lesion, especially as a secondary
lesion ; as a primary lesion it is somewhat uncommon.
Dr. Peyton Blakiston has paid great attention to this lesion,
and has demonstrated that it accompanies left side disease
much more commonly than was previously surmised. It is
often found in connection with disease of the mitral valve.
Many years ago, in a very clever article, Dr. T. King tried to
establish that there existed what he called " the safety valve
action of the tricuspid," an idea which is still quoted in many
works on heart disease and physiology. His experiments
were, however, imperfect, and his conclusions hastily drawn^
for so far from tricuspid regurgitation having any protective
action, it really inaugurates the most serious secondary
changes. But the experiments of King need much careful
investigation to demonstrate their inaccuracy, and for those
who care to investigate the question, they may refer to a
paper by the writer, in which this is examined in connection
with the hearts of the diving mammals, &c.*

When the tricuspid becomes imperfect, it may possibly
arise from sudden engorgement of the right ventricle, but

* " Edin. Med. Journ.," Dec, 1870.

136 THE HEART AND ITS DISEASES.

this is only as a temporary condition, and it is only possible.
Nor does this condition when more permanent lead to per-
sistent tricuspid regurgitation, for, as Rokitansky shows,
this dilatation of a chamber is accompanied by dilatation of
the valve, and chordae tendineae and musculi papillaries, so
that dilatation does not lead to insufficiency of the auriculo-
ventricular valves as long as that valve apparatus is itself not
the subject of disease. The commonest pathological condition
which leads to tricuspid insufficiency is the same as in the
mitral, viz., shrivelling and distortion of the small valve of
the fixed wall, with its cords. This sometimes proceeds until
the tip of the forefinger can scarcely be inserted betwixt the
valve and its wall. Similar changes may affect the other
portion of the valvular apparatus, but less commonly. The
right auricle is not nearly so liable as the left to suffer fi'om
endarteriitis deformans, and does not become so altered by
distension. It may hypertrophy, true, but it is more essen-
tially venous, and suffers rather passive stretching. Under
this stretching it sometimes becomes extremely thin and
transparent, and when held up to the light is seen as a
nearly transparent fibro-serous membrane with muscular
fibres at intervals.

The changes in the right auriculo-ventricular valve have
often been attributed to a sort of sympathy of one side with
another — a fact about some ailments ; but in this case we
have the more direct explanation that until the mitral is
affected no stress is thrown on the right side of the heart.
This stress leads to dilatation and hypertrophy of the right
ventricle, and from that more stress on the valves and their
attachments. This is more probable, and is rendered more
80 that one of the best marked cases of tricuspid regurgita-
tion the writer ever saw (so far as a diagnosis can be
accepted that is not corroborated by post mortem) occurred
immediately after an attack of pneumonia in an old man of
84. The symptoms were all marked ; dropsy set in while
he was still walking about, and in two months all was over.
There may be something in the sympathy betwixt the two
auriculo-ventricular valves, but we must be guarded about it
when another much more obvious cause is in operation.

VALVULAR DISEASES. 137

We will follow now the secondary consequences of
tricuspid insufficiency. When this occurs it is obvious that
at each ventricular contraction a backward rush of blood will
over-distend the veins behind. These veins are to some slight
extent muscular at their terminations, and as such con-
tractile. This and the contracted condition of the auricle
will to some extent impede the backward flow of blood ; but
its great stress falls on the elasticity of the veins, which is
already considerably involved by their engorgement. The
engorgement of the venae cavse leads to general venous
stagnation. The coronary circulation is pretty well pro-
tected against venous stagnation by the separate outfall ot
its veins into the right auricle. The stagnation in the venous
system is not equable in consequence of the venous valves.

Thus the internal jugular prevents direct regurgitation
into the circulation within the encephalon, while the counte-
nance is early engorged. These venous valves, too, prevent
regurgitation into the arms and lower limbs. The great
early stress is thus thrown on the portal circulation, which,
by its external openings can most quickly relieve itself by
natural discharges. This fortunately enables the system to
continue its existence a little longer, even under a very
advanced condition of disease. We have, as related in a
previous chapter, congestion of the liver, and in the young,
rapid development of connective tissue and the formation of
liver cirrhosis. So, too, in the old; though in the old we
often find a condition of vascular engorgement of the liver,
with notable increase in bulk. The Germans state that this
regurgitation into the veins of the liver makes a "liver
pulsation" isochronous with the heart's contractions. But
to this we will return. Also congestion of the bile ducts,
alterations in the bile itself, &c. Catarrh of the stomach
and intestinal canal are very common, and a source of
trouble to the patient ; haemorrhoids, &c.

The spleen is enlarged or cirrhotic. The kidneys begin to
suffer from this venous congestion, and the urine is scanty,
laden with urates and albuminous, whatever may have been
its condition at an earlier period. Increase in its interstitial
tissue is marked, and often may be seen marks of old standing

138 THE HEART AND ITS DISEASES.

mischief amidst the new formation. There is in women
mennorrhagia, metorrhagia, and leucorrhoea, and in men
prostatic enlargement and heematocele (Oppolzer). There
is effusion into the peritoneal cavity generally. But sooner
or later the distension of the veins leads to insufficiency of
the venous valves themselves, and then we have oedema of
the feet, spreading upwards into the scrotum, &c. In spite
of the authority of Rutherford Ilaldane, Oppolzer, and
others, it must be admitted that we often have dropsy, which
passes away, and does not return for long, which could
scarcely be the case if the venous valves were become insuffi-
cient, or the tricuspid affected. Still no doubt when the
venous valves are become insufficient, persistent dropsy
follows and remaius. The valves of the internal jugular
become affected, and drowsiness, harassed by horrible dreams,
sets in, gradually increasing to coma. Again, there may be
a great deal of venous congestion within the encephalon
long ere the venous valves become insufficient. The venous
flow can only be somewhat limited through those valves
forward when opposed by great congestion in the vense
cavae, and an observable amount of congestion of the contents
of the encephalon may and does commonly occur long before
there is any decided effusion into the ventricles, or increase
in bulk in the cerebro-spinal fluid, &c., which follow quickly
when the valves of the internal jugular become affected.
This cerebral congestion is first apparent in the mental mani-
festations, in disagreeable dreams when asleep, in caprise,
petulance, irritability, erroneous calculations, rash specula-
tions, coldness, or suspiciousness of old friends, tendency to
form new connections in opposition to old ones, and, indeed,
a thousand alterations, which are very trying to the friends
and the medical man, while they must also be grave trouble
to the patient himself.

The diagnosis of change in the right ventricle, &c., when
following left side disease, is not at all peculiarly difficult.
The changes in the right side of the heart in primary right
disease are not so well marked, as the disease rarely remains
long enough to develop them well. In the wake of left side
disease, and in addition to the changes previously inaugurated.

VALVULAR DISEASES. 139

we get a new series of changes, to inspection, palpation, per-
cussion, and auscultation. On inspection we find a diffused
heaving, extending from the right apex in a curve towards
the epigastrium, and even to the right second intercostal
space ; indeed a distended and hypertrophied right auricle
may often be seen playing at that point.

Palpation assures us of this, and distinguishes the super-
ficiality of the changes as compared to left side disease. The
distended right ventricle lies more upon the diaphragm than
in health, and the heart itself lies more horizontally across
the chest than under other circumstances. The left apex
beat is often undistinguishable, unless there be left side
hypertrophy, and then it may be felt beating rather to the
left of the normal left apex. This position of the right
ventricle communicates its impulse to the liver, and espe-
cially the left lobe ; this is the great cause of the " liver
pulsation," though it is possible that the venous regurgitation
into the liver may aid in producing it. We can also feel the
right auricle in action in the right second intercostal space.

These two aids will materially assist us in percussing
correctly the outlines of the dilated and hypertrophied right
heart, and to distinguish betwixt the sounds produced by the
various organs, for to map out the right side of the heart is
more difficult, and contains more elements of error than does
mapping out the left side by percussion. Still percussion,
with its accompanying sensations of resistance, will often be
of aid to us in examining the right side of the heart, and
more so as regards the right base and the right auricle, the
latter often enabling us to describe its boundaries by per-
cussion.

Auscultation will tell us more of the changes which have
gone on. In the first place is the important accentuation of
the second sound at the pulmonary valves. Then there is
the loud and strong sound of the increased muscular con-
traction, and so long as the tricuspid is not much affected, a
sharp sound from the auriculo-ventricular valves, driven
together with increased force. But when the tricuspid has
become affected, this sound is no longer heard, and in its
place is i\ soft blowing sound heard over a most limited space

140 THE HEART AND ITS DISEASES.

of area. Just at the point of the ensiform cartilage, and
nowhere else, is this sound heard. It is unique, and not likely
to be confounded with mitral regurgitation or aortic regurgi-
tation. True it is, that if in a case of supposed tricuspid
regurgitation, a stethoscope be applied over the tricuspid
area, a murmur faint and low may be heard, but it can be
traced away, and located in another quarter. Often it can
be traced to the nipple, or even behind it, in mitral regurgi-
tation. Sometimes, too, an aortic regurgitant murmur will
be heard with great clearness in the tricuspid area, but it can
also be traced elsewhere and fixed. This murmur is significant
when heard_, but it is often wanting, and even after being
distinctly audible for a while, be not longer so as the patient
grows nearer his end. This may be that the regurgitation is
not marked enough, or sufficiently powerful to any longer
give rise to an audible murmur. In the same way, as needs
pointing out more especially, when tricuspid regurgitation
becomes marked, the murmurs of the left side become
inaudible. In two well-marked cases at least the writer saw
this, where extensive aortic obstruction co-existed with a
" button-hole " mitral ; in one case no murmur could be heard
in the left side, and in the other only a faint one over the
pulmonary area. The effect of tricuspid regurgitation in
masking left side lesions needs more observation. It seems
probable that in both these two cases the tricuspid regurgi-
tation permitted so much backward flow of blood, that the
blood stream in the left heart was unequal to eliciting audible
evidence of obstruction offered to its flow.

We often find, too, in auscultation of the right heart
irregularity, which is not so readily discernible in the radial
pulse, especially in mitral stenosis. Here the right heart is in
great distress often, when no difficulty is offered to the flow
of blood from the left ventricle. This irregularity, often
combined with palpitation, in the right heart, as almost con-
fined to it solely, is not uncommon, and specially in the
attacks of cardiac dyspnoea, to which this condition is liable.
In fact, very often tlie objective symptoms are really con-
nected with the condition of the right heart, though when
becoming marked they are communicated to the left heart by

VALVULAR DISEASES. 141

the muscular fibres common to each, and by it to the radial
pulse. Cardiac excitement is often really right side, and in
these conditions there is no difficulty in so diagnosing it.
This condition of the heart and tricuspid regurgitation are
also manifested by ''jugular pulsation." This when marked
may be regarded as pathognomonic of tricuspid insufficiency,
as the valves in the narrow portion behind the sterno-cleido-
mastoid only become insufficient from such dilatation as is
produced by tricuspid regurgitation only. A finger properly
applied will arrest it. This distinguishes it from carotid
visible pulsation, which often occurs in aortic regurgitation.
But the absence of jugular pulsation does not establish the
fact of the non-existence of tricuspid regurgitation in its
earlier stages ; its presence proves that marked tricuspid re-
gurgitation is fully established, and that the regurgitation
has become sufficient to dilate the veins until the venous
valves become visibly insufficient.

Prognosis, — The prognosis of tricuspid regurgitation is a
very important part of it. So important, indeed, is tricuspid
insufficiency in its effect upon the prognosis that the prog-
nosis may truthfully be said often to hang upon the resistance
offered by the tricuspid.

So long as the tricuspid remains sufficient, there is an
element of hope as regards duration of life in the case. With
one valve left sound behind a muscular chamber, something
may be done, and the right ventricle may yet be acted on,
and some compensation maintained. But let the last valve
become insufficient, and the aspect of the case changes at
once. There is nothing now left but the feeble barrier of
the resistance of the veins already distended, and now to be
subjected to the direct distending force of the backward rush
of blood propelled by a dilated and hypertrophied ventricle,
a force veins were never intended or constructed to with-
stand. To this new distending force the veins rapidly yield,
the last changes commence, and the case is quickly hurried
to a termination. So when tricuspid disease is primary, the
case soon runs its course. For that regurgitation under
ventricular impulse is ruinous to the veins, and the case

142 THE HEART AND ITS DISEASES.

commences about the point when an ordinary case of heart
disease is putting on its last and worst aspect.

Treatment.— li is obvious from the pathology of tricuspid
regurgitation, that any attempt to act on the heart could
hold out no prospect of success ; it could only increase the
force of the right ventricle in destroying the veins behind.
All treatment then, must naturally belong to the last division
of treatment of heart disease, viz., the treatment of sequelae.
Drastic cathartics are the most effectual means at our dis-
posal, and five or six copious fluid motions relieve the venous
engorgement, including the cerebral congestion, and for a
brief period relief is experienced. No diuretics can be ex-
pected to be of any avail here, for with that leaking tricuspid
it would be futile to attempt to increase the arterial pressure.
Incisions, or needle-pricking, may be resorted to, but they
contain no hope of any real relief, and make the patient's
bed, &c., very uncomfortable.

DISEASES OF THE MUSCULAR WALLS. 143

CHAPTER VIII.

Diseases of the Muscular Walls of the Heart : Myocar-
ditis— Fatty Degeneration — Symptoms, Pathology,
&c. — Fatty Infiltration — Connective Tissue Hyper-
trophy— Atrophy — Amyloid Degeneration — Syphili-
tic GuMMATA — Tubercle — Cancer — Polypi.

In describing the diseases of the muscular walls of the heart
great hesitation will often occur in consequence of the diffi-
culty of the subject, and the acknowledged imperfection of
our observations. A great deal has, undoubtedly, been
cleared up, but much yet remains to be learnt. Not only are
the pathological changes themselves, both gross and histolo-
gical, still somewhat obscure, but of the causation in many
cases we know absolutely nothing. We can understand
diseases of tissue, chiefly degenerative, arising from such
obvious causes as embolism or ossification of the nutrient
artery ; or that the heart-wall, in common with other muscu-
lar structures, is the seat of syphilitic gummata, cancer, or
tubercle. But as to changes commencing in a low inflam-
matory process we know, causatively, absolutely nothing.
To what extent these changes are connected with derange-
ment of the complex nervous supply of the heart, as to
whether there is disturbance in the vaso-motor nerves, the
nerves commonly called trophic, or in both, or even neither,
we cannot yet even speculate. The difficulty of the subject,
the absence of the necessary preliminary knowledge, both of
nerve-inflammation and of inflammation of muscles, suffi-
ciently explain the absence of observations yet, and for some
time to come, in all probability. It must be confessed that
there is much that we could much like to know, and would
willingly and eagerly learn, but it is not yet possible, and we
must rest, not satisfied, but patient, for the present with
what is at our disposal. It will then be the writer's aim to

144 THE HEART AND ITS DISEASES.

give an account, as clear as is within his power, ot the
present state of medical knowledge, perhaps sometimes
rather medical opinion, on the various changes which go on
in the muscular walls of the heart, commencing with changes
connected with inflammatory action, and then describing
those changes, which can scarcely be called inflammatory in
the ordinary acceptation of the word. Inflammation of the
muscular structure, or myocarditis, will come first, and, after
it, the slower or later changes will follow, as fatty degenera-
tion, false hypertrophy, atrophy, and the chronic inflamma-
tions of special character as syphilitic gummata, tubercle, &c.

Acute Myocarditis. — Rindfleisch commences his account of
myocarditis by assuring us that it is the darkest chapter in
all pathology, with which scarcely comforting assurance it is
impossible to differ. Inflammation of all muscular structure
is very imperfectly understood^ and is not so frequent as
inflammation in structures where we have a secreting func-
tion, which is a great cause of their derangement. Myocar-
ditis when acute is usually more or less general, and is
found in pyrexiae, especially when sceptic in character, and
along with endocarditis and pericarditis. It commences,
according to Virchow, either in the niuscular bundles them-
selves (parenchymatous myocarditis) or in the intermuscular
areolar tissue (interstitial myocarditis). This sometimes
runs into pus, and then it is denominated purulent myocar-
ditis. The structure of the heart is at first infected and of
a dark red colour, and later becomes rather a greyish yellow,
or greyish red, with accumulations of pus in minute masses.
Under the microscope the primitive bundles of muscular
fibre become increased in bulk and swollen with fluid, and
the cross markings become indistinct. To the touch the
heart walls feel soft, boggy, and easily torn, and the struc-
ture is easily broken up into irregular fragments. The
accumulations of pus often run together and form an irregular
abscess, which may open through the endocardium into the
circulation.

This form of myocarditis is commonly found in pyoemia,
where the name metastatic is often applied to it, along with
endo-metritis or puerperal fever, typhus, scarlatina, and

DISEASES OF THE MUSCULAR WALLS. 145

Oppolzer states not rarely with cholera. It has been
noticed as a common cause of death in relapsing fever,
where patients not uncommonly die suddenly in the con-
valescence from some exertion which is too much for the
weakened heart. In what myocarditis differs from the
wasting which goes on in muscular structure ordinarily when
any heightened temperature is maintained for some time con-
tinuously it is impossible to say. It is possible that it may
be found rather a difference of degree than of kind. That
there is a great debility in the heart in many febrile cases
we know quite well, and in the dead-house impaired struc-
ture of the heart walls is rarely absent in puerperal endo-me-
tritis ; but at this point the disease assumes an unquestionably
fatal character, and bow far it may proceed compatibly with
recovery it is impossible to say.

Symptoms. — There are no positive symptoms of myocar-
ditis, and Oppolzer states that it is not easy to find a disease
with so dark a combination of symptoms (symptomencom-
plex) as in myocarditis. Like all affections of the heart
walls there is not a prominence of objective symptoras, and
palpitation is not usual, while the subjective symptoms are
those common to all cardiac failure. A fast, feeble, com-
pressible, and even uncountable pulse is perhaps the most
reliable of all symptoms. Whenever there is acute debility
in the heart the contractions become increased in frequency
and diminished in force in proportion to the debility, whether
due to myocarditis or not. There is often, too, pain in the
region of the heart, and it is to the myocarditis which accom-
panies endocarditis and pericarditis that the pain is stated to
be due which so often accompanies these affections, and yet
is not necessarily present in them. But in acute myocarditis
pain is commonly absent ; its presence is of some value, but
its absence proves nothing. There is not unfrequently pain
in the articulations ; but then, again, acute myocarditis is so
rarely, if ever, found alone, and without some general affec-
tion, that it is impossible to say what general symptoms
belong to it, and what to the systemic affection. Probably
extreme rapidity of the pulse, with great weakness in it, is
the most reliable sign of myocarditis when acute and diffuse.

L

146 THE HEART AND ITS DISEASES.

It is said that the blood is dark and of a violet colour, but
that is a post-mortem appearance, which is of no use in life,
and even if heemorrhage did occur, the difficulty of the
accompanymg systemic affections would effectually prevent
any diagnostic value being attached to any peculiar appear-
ance in the blood.

Proanosis and Terminations. — It is to be feared that about a
disease whose existence is rather a matter of speculative
probability, founded on the revelations of the dead-house,
than demonstrated by positive evidence of its presence, it is
difficult to express any but the most guarded opinion. Much
would depend on the nature of the general complaint, and a
very difficult prognosis is probably warranted in relapsing
fever with evidences of gi-eat cardiac debility, where the
presence of acute myocarditis is somewhat more than a mere
probability, than in similar circulatory condition in pyoemia
or puerperal fever. It must be admitted that in the present
state of our knowledge our prognosis must be formed rather
on the general condition and the fatality of the general
malady than on any circulatory signs or symptoms that
might in each case be deemed to be due to myocarditis. We
all know well enough that any high mounting of the pulse,
Avith corresponding feebleness of it is a bad prognostic sign
in all acute diseases, and especially if it in time be accom-
panied by irregularity. How far a somewhat excited action
of the heart, giving a fictitious appearance of strength not
found in the pulse, would enable us to ascertain a greater
probability of myocarditis, as an awkward complication in
any acute affection, is as yet unascertained ; it is merely
probable. As to the terminations of acute general myocar-
ditis, it must be admitted that there is some reason for
supposing that it is not rarely followed by recovery. Those
cases of relapsing fever, &c., where there are the same sus-
picious appearances in tlie circulation, which recover, and
these are the majority, can differ but little, if at all, from
those where some sudden effort or exertion has been followed
by a fatal result. Tliere are grounds for thinking that it is
frequently followed by recovery, as well as the corroborative
evidence furnished by scars (the scars of Dittrich) which ai-e

I

DISEASES OF THE MUSCULAR WALLS. 147

commonly found on hearts in the dead-house, and which are
evidently the remams of some former affection, while at the
same time the condition in which hearts are also found, on
section, after acute pyretic affections, leaves no doubt in the
mind that in many cases the affection of the heart must have
been a factor, if not the chief one, in producing the fatal
result. But as to when, or how, we are to determine that the
affection still continues at a point compatible with recovery,
and when that point is irrevocably passed, we are yet in a
darkness from which we can only hope some day to emerge.

Treatment. — This can only be general, and such as we
should apply in any similar condition. Antiphlogistics, so
called, which are supposed to owe their efficacy to their lower-
ing effect upon the heart, are obviously out of place here.
Agents which will keep it itself going are indicated, and among
these in acute affections of the heart and its serous mem-
branes ; the Germans place digitalis first. Stimulants and
food of an easily digestible character are indicated, but each
case must of necessity rest for its treatment on its own
peculiarities. One thing is certain, that in the convalescence
from all pyrexiae, where there has been myocarditis, or a
strong probability of it, all effort and exertion must be strictly
forbidden. Every one with much experience of a fever hos-
pital knows but too well that every now and again con-
valescent fever patients die suddenly, especially after exercise,
and that death is commonly referable to over4axation of the
heart, weakened by myocarditis. 'Iff^//; p xm-I"^

Chronic Myocarditis. — The heart wall is liable to other
changes of a more gradual character than the affection de-
scribed above, but which are still of an inflammatory nature,
and these may best be described as chronic myocarditis, as
distinguishing them from the acute myocarditis just described.
These changes are usually of a more local character, and are
not so general or diffuse. The favourite seats are the left
ventricle, and, according to Rokitansky, by preference, the
apex, the right ventricle, more rarely the right auricle, while
the left auricle possesses almost entire immunity. These
changes are various, but commence in an inflammatory pro-
cess in which the heart fibre becomes altered as described

L 2

148 THE HEART AND ITS DISEASES.

above, but more slowly, and in some instances not to the
same extent. Thus a process may go on, in the left ventricle
chiefly, which may lead to such softening of the heart fibre
as Avill lead to the formation of cardiac aneurism, that is,
bulging outwards in the affected part, while at other times
a complete abscess maybe formed, by the molecular death of
the part supplied by a small vessel closed by an embolon.
There are various stages reached which have not yet been
sufiiciently examined microscopically to demonstrate their
pathology thoroughly. A description must then be confined
to the naked-eye changes, and, as this local myocarditis is
not itself fatal until rupture of the heart walls occur, it is
only the more advanced results that come under notice.
The earlier stages are not presented to us, or so rarely, that
no account of them can yet be constructed. It would appear
that this myocarditis is liable to proceed further at some
parts than others, as if a point were reached in the process
when repair became impossible, while the surrounding tissue
becomes perfectly restored. The evidence of this is found in
the scars and puckers, so commonly seen in the dead-house,
showing where old destruction had gone on, and scattered
over the surface of the heart, more or less, and giving to the
aftected part a wrinkled appearance. This inflammatory
process, with its ultimate formation of contractile cicatricial
tissue, is sometimes found near the right or left conus arte-
riosus, and then forms an obstruction to the flow of blood,
and is called the true cardiac stenosis of Dittrich.

At other times the inflammatory process produces merely
a softening of the affected tissue, which causes it to yield
before the distending force of the blood in diastole, and then
is formed a bulging, or true cardiac aneurism. This is most
commonly found in or near the left apex, but has been found in
the septum ventriculorum. It may vary in size from a small
aneurism no larger than a bean up to a size equal to the heart
itself. The visceral pericardium stretched over it may become
almost lost and invisible, while the endocardium lining it may
become atheromatous or covered with villous vegetations.
There is always great risk of these aneurisms bursting, and
more so if the heart, from any cause becomes hypcrtrophied,

DISEASES OF THE MUSCULAR WALLS. 149

for the more the pressure centripetally is mcreased in the
sound, acting, parts of the heart wall, the greater must be the
centrifugal pressure on the parts which are not in action.
The formation of partial cardiac aneurism (to distinguish it
from general eccentric dilatation, which of old was sometimes
called cardiac aneurism) has been studied and described in
our own country chiefly by Canton and Wilks.

Sometimes the papillary muscles are especially affected
by this chronic inflammatory action, which is degenerative
in its character. In these cases there is auriculo-ventricular
regurgitation from imperfect closure of the valves in conse-
quence of inability in the affected papillary muscles.

At other times when there has been more acute myocar-
ditis, with here and there the formation of small accumula-
tions of pus, on the recovery of the inflamed portion, the
masses of pus become encapsuled in a pyogenic membrane of
connective tissue, and are thus rendered no longer a source
of danger from rupture. When myocarditis is, however, the
result of embolism of one of the smaller branches of the
coronary circulation, as occurs after suppuration or destruc-
tion in the lungs, the portion of muscular wall thus deprived
of its nutrition (for there is no communication betwixt the
coronary arteries and thus formation of collateral circulation ;
Quain) becomes not perhaps so much inflamed as subject to
molecular necrosis, and the formation of abscess. This un-
toward accident may lead to death by perforation of the heart
wall dnectly, or may discharge itself into the circulation, and
form cardiac aneurism, which should strictly be called
" false, " as distinguished from " true " cardiac aneurism,
and thus produce a fatal result, from rupture of the sac at
some later period.

Symptoms. — The symptoms of partial chronic myocarditis
are somewhat obscure, and in the case of small scars pro-
bably rio special symptoms are found. At other times there
are pains in the chest, dyspnoea, impeded circulation, feeble
pulse, with increased rapidity and irregular action in the
heart itself. There may be palpitation even in the sound
portions of the heart. It was thought by Piorry that he
could detect a peculiarity in the pain of myocarditis which

150 THE HEART AND ITS DISEASES.

rendered it pathognomonic, and that was its exacerbation on
systole. He thought that it was possible for the sufferer to
distinguish an increase in the amount of pain on each ventri-
cular contraction. There is an a priori objection to this in
the rapidity of the pulse, and the fact that some time is re-
quired .in the transmission of sensations by the nervous
system, while impressions rapidly repeated acquire the cha-
racter of continuousness. No other observer has been able
to elicit this peculiarity in the pain of myocarditis, and it is
only necessary to allude to this idea of Piorry's to prevent
youthful readers from wasting time in attempting to find it.
When there is aneurism of the apex of the heart, Skoda has
thought it possible to detect an intensified bulging of the
corresponding intercostal parietes, and he is entitled to
credence from the accuracy of his observations. Where there
is the stenosis of Dittrich, a systolic murmur will be heard at
the base of the heart ; and when the papillary muscles are
afiected, a systoUc murmur at the right or left apex, or rather
at the ensiform cartilage, or the left nipple. The contractions
of the ventricle are usually somewhat feeble and unrythmical,
and occasionally unusually slow ; but the diagnostic vahie of
this last symptom has not yet been appraised.

Prognosis and Terminations. — The course of chronic myo-
carditis is so various that the difiiculty of diagnosis is quite
equalled both by the difficulties of prognosis and of treat-
ment. The prognosis can only be founded on general
symptoms and experience, the cases are too rare to enable
any special rules to be formed. When this symptom of Skoda
is observed, it will indicate a condition liable to sudden death,
only to be met by guarded inactivity, and where an un-
favourable ultimate prognosis is warranted. The subject of
myocarditis is too shrouded yet to admit of any dogmatising,
and the medical man, who can diagnose it, is, in my opinion,
quite capable of forming a prognosis and deciding on a line
of treatment for himself without any extraneous aid.

At other times no doubt myocarditis is the precursor of
fatty degeneration and other chronic conditions of the heart
walls of sufficient importance to entitle them to separate
consideration.

DISEASES OF THE MUSCULAR WALLS.

151

Fatty Degeneration. — From inflammation of the muscular
structure of the heart we now come to a less unknown, but
still difficult subject, namely, fatty degeneration of the heart.
In consequence of confusion in nomenclature, as well as two
distinct pathological processes, each fatty in a totally different
way, it will be necessary to be somewhat lengthy in order to
be explicit on this subject. There are two morbid processes
connected with the development of fat in the heart, which
were at one time confounded, but which are distinctly differ-
ent. To establish the best of all distinctions, a broad ana-
tomical one, it may be stated that the one is an affection of
the muscular fibre itself, the other an ptffection of the inter-
muscular connective tissue. The one is connected with the
degeneration of the muscular fibre, allied to the fatty degene-
ration of a post-parturient uterus ; the other is a develop-
ment of fat in the areolar tissue, a true interstitial growth,
which affects the muscular fibre merely by pressure on it.
The difference will be most strikingly demonstrated by
placing side by side these two plates of the different con-
ditions, taken from Rindfleisch's " Pathological Anatomy."

Fia. VII. Fig. Till.

mm

Fatty Degeneration of Heart Fibre,

showing more and less advanced

stages (after Rindfleisch).

Fatty Infiltration of Heart
(from Rindfleisch).

The distinction is clearly apparent ; the one is an affection
of muscular fibrillaB, and the other of the interstitial connec-

152 THE HEART AND ITS DISEASES.

tive tissue. Willi the second form we are not yet engaged ;
it will be considered afterwards, along with the other affec-
tions of the connective-tissue of the heart.

True fatty degeneration of the heart is a consequence
not rarely of parenchymatous myocarditis, especially in the
more acute conditions associated with relapsing fever, puer-
peral fever, &c,, and notably phosphorus poisoning (E. Wag-
ner). As such it is properly considered next in order to
myocarditis ; but it is in its more frequent and chronic con-
dition a degeneration, which Dr. E. Quain has described as
the result of a chemical or physical change in the composition
of the muscular tissue itself, independent of those processes
which we call vital. — (Lumleian Lectures, 1872.)

In order to elucidate this subject, it may not be undesi-
rable to wander, for a brief time, from the exact subject in
hand. Fatty degeneration is a process certainly not neces-
sarily connected with life : in fact it is somewhat antagonistic
to the idea of vitality, it is a species of molecular death. It
is, however, a normal process, as seen in the uterus after
delivery, where the mass of muscular fibre, having fulfilled
its function, undergoes involution by resolution of its tissue
into fat and ammonia. So, too, muscles which are suddenly
cut off from their nutrition, as by ligature of an artery, undergo
fatty degeneration, until their normal nutrition is restored by
the establishment of collateral circulation. In fracture also,
where muscles are prevented from use for a time by our
surgical appliances, this disuse leads to a passing degenera-
tion. The decay of the formed material of the muscular
fibres takes the form of fatty degeneration, when no longer
normally removed and replaced by new material. There is
a sort of death in the process, that is, the decayed is not
replaced by new material. For this same fatty degeneration
occurs in muscle when placed in running water, or in a solu-
tion of nitric acid and water, very highly diluted. The
development of fat, or adipocire, is a gradual process in which
the muscle becomes paler, softer, less consistent, and ulti-
mately is found a piece of dirty white fat, all structural
formation being lost. The gradual development of fat in
the muscular fibre can be watched imder the microscope, and

DISEASES OF THE MUSCULAR WALLS. 153

here there can be no question that the fat is the result of
retrograde metamorphosis of the muscular fibre, and not any
infiltration of fat from without. The complex albuminous,
or protein compounds, are undergoing resolution into their
primitive elements, hydrocarbons and ammonia. Wagner
even enclosed albuminous substances in the peritoneal cavity,
and found them undergo this fatty degeneration. It Avould
appear indeed that this is the retrograde tissue metamorpho-
sis of sarcous elements, the true histolysis of muscular fibre
when it is no longer renewed from the germinal matter ; no
matter how that is brought about^ whether it is due to
incomplete or imperfect blood supply, or the arrest is due to
death.

It would appear that the non-renewal of tissue from the
germinal matter is the cause (or, if not that exactly, furnishes
the circumstances under which it goes on) of this fatty his-
tolysis. We now know from the researches of Lionel Beale
chiefly, that growth is confined to the germinal matter, and
that formed material merely fulfils its function, and then
undergoes molecular histolysis ; the place of the worn-out
material, or the material which has run its course, being filled
by new formed material from this germinal matter. The
knowledge of this would prepare us for the fact that fatty
degeneration of the muscular structure of the heart commences
in the nuclei, in the germinal matter. Paget observed granu-
lar degeneration in the nuclei at a very early stage, and a
reference to the plate above will show that the fatty particles
are found first around and in the neighbourhood of these
nuclei. When examined under the microscope, the first
changes will be found to consist of the appearance of dark
clots, not unlike the pigment granules of brown atrophy of
the heart ; these are stated by von Dusch to consist of the
colouring material of the muscular fibre. This is not incon-
sistent with Avhat we know of the change of colour in the
frog's skin, which is achieved by the diffiising and gathering
together of the pigment matter. When difiiised a dark
colour is given, when aggregated in little masses a lighter
colour is produced. So in the muscle of the heart, it is pale
and colourless, and its colouring material is found in diminu-

154 THE HEART AND ITS DISEASES.

tive masses. The cross-markings, or striae, of the muscular
fibrill^B appear faint, and further on become lost. The dark
clots enlarge, and become transparent, and are seen as globules
of fat, which Dr. Quain says " are extremely like the oil-
globules of milk, and appear to have a mere albuminous
envelope." Still later they have increased in number and
size, till the muscular fibril with its cross-markings is lost,
and the sarcolemma contains merely a number of fat globules
in rows, or, as Rokitansky has described them, "like strings
of beads." The process does not pass on by continuity from
one muscular bundle to another, or even from one fibril to
another in a bundle, but is irregular ; and side by side may
be seen fibres in all conditions, from the still normal to the
most advanced condition, with fibrils in various stages among
them.

During this process the muscular fibre has been under-
going naked-eye changes, and changes in consistency. The
colour has become paler, for the reason given above, and is
of a dirty yellow, or of a "dead-leaf" colour, somewhat
unevenly though, and some parts are paler than others. The
consistency is altered, the wall breaks down readily under
the finger, and a finger may, in advanced cases, be pushed
through the ventricular wall, as if through one or two thick-
nesses of wetted paper. The tissue is friable, and tears with
a sort of fracture, and crumbles down under the finger and
thumb. It feels greasy and unlike normal heart-wall, and a
warm knife passed through it looks oily. There is not neces-
sarily any change in bulk, nor does the degenerate structure
take on dilatation inevitably. The change may be localised
and confined to some particular portion, especially when due
to disease of the coronary arteries. This may give a mottled
appearance to the heart, but as commonly, and more so, the
heart is generally of this pale-bufF colour, the blue coronary
veins looking marked and distinct. These veins with their
deep blue form a striking contrast to the paler tissue around
them, and are often themselves tortuous and atheromatous.
Nor is there necessarily a deposit of fat along the sulcus in
which the veins lie, which makes the contrast in colour
striking. The coronary arteries nre not uncommonly tortu-

DISEASES OF THE MUSCULAR WALLS. 155

Oils, rigid, and atheromatous. The whole appearance in a
well-marked case is that of degeneration, of partial death,
or imperfectly renewed life, which is quite borne out by the
microscopic appearances. It must not, however, be supposed
that we are yet in possession of all that we can hope to
know of this interesting form of histolysis, and much must
be added to what we yet know ere our knowledge even ap-
proximates completeness ; but such as is known is fairly
certainly ascertained, and may be relied upon. It has been
conjectured that this degeneration more readily occurs in
those new fibres which arise in hyperplasia, commonly called
hypertrophy ; that the new fibres more readily take on de-
generation than the original ones, but of this there is no proof;
any analogy founded on the more ready decay of new growth
than normal tissue, does not hold good in hyperplasia, where
the new fibres are as perfect as the original ones.

Causation. — The causation of fatty degeneration of the
muscular fibrillee of the heart is yet so unascertained, that
the circumstances under which it occurs must be supposited
for it, with such inferences as they may appear to indicate.
The presence of it where the blood supply of a part of the
heart is cut off, partially or more completely, shows that it is
closely allied to the deprivation of blood, and thus the non-
removal of worn-out material, as well as the -non-supply of
new tissue. Thus it will occur in an intense degree in the
part supplied b}' an arterial twig when that vessel is choked
Avith an embolon, whether, in acute disease, as an embolon
from gangrenous lungs, or consisting of a small mass of
atheroma washed off some atheromatous tubercle, or out of
an atheromatous patch, breaking up and forming an ulcer in
the arterial wall. It is, as a more general and diffused, but
very chronic and gradual, condition, associated with an athe-
romatous condition of the arterial system. Here it has been
described as a preservative lesion. Sir Wm. Jenner, in his
address before the British Medical Association, at Leeds, in
1809, stated that when this announcement was first made in
the Pathological Society of London, it was received with
shouts of laughter. But as knowledge on the subject became
more general, it was found that the statement was strictly

156 THE HEART AND ITS DISEASES.

founded on fact. There is no doubt that when the arteries
become atheromatous and rotten, an unimpaired heart would
be a most unquestionable source of danger, and -great danger,
while an impaired condition of tlie heart avoids the risks and
is thus preservative; though, of course, it must be owned
that it substitutes new risks in itself for the other risks it'
obviates. That, however, a fair balance of power between a
degenerate heart and degenerate arteries gives a better
probability of temporary continuation of life than if the
arteries were exposed to the shock of a perfectly normal
heart, will not be questioned by many clinical observers.
This association betwixt fatty degeneration of the heart and
atheromatous arteries is not, however, accidental, and the
consideration of the association may not be either out of
place, or uninstructive. The heart, as we saw in the opening
chapter, is dependent for its blood supply on the arterial or
aortic recoil. It thus receives its blood supply during its
period of sleep, of muscular quiet, when the flow is not im-
peded, as would certainly be the case were it to receive its
blood supply from the ventricular systole, its own period of
activity. The amount of aortic recoil, then, affects the blood
supply through the coronary arteries. When from any cause
there is increased arterial tension, there is increased aortic
recoil and freer supply of blood to the heart itself. Thus
hypertrophy tends to maintain itself; dilatation tends to
defective blood supply and heart degeneration. These causes
affecting the heart nutrition through its blood supply, are
quite distinct from any vaso-motor variation which may be
carried on through the cardiac ganglia, and depending on
impressions made on them, probably by the sensation of dis-
tension. When, then, we have an liypertrophied heart pretty
forcibly dilating the aorta, and thus leading to good recoil,
there is good blood supply to its own structure. But, let
that strong recoil lead to aortic valvulitis and insufficiency,
so that the blood is no longer arrested on its backward course
perfectly, and thus the coronary vessels filled, and we find,
as Mauriac has shown, that that liypertrophied muscular
wall is rapidly affected by fatty degeneration. So, too, when
the arteries, and especially the aorta, are, as a consequence

DISEASES OF THE MUSCULAR WALLS. 157

of this powerful distension, themselves becoming athero-
matous, they then become dilated instead of recoiling per-
fectly on each systole, they become less elastic, and their
recoil is imperfect ; then the imperfect recoil leads to insuffi-
cient blood supply to the coronary arteries and impaired
nutrition of the heart itself. Thus we see that as time rolls
on the atheromatous arteries and the degenerate heart
become adapted in power to each other, and a preservative
balancing of forces tends directly to the continuation of the
existence of the organism. The weakened heart tests less
forcibly the diseased arterial coats, and thus the risk of
rupture of them is lessened. But as that risk is lessened,
unquestionably other risks are supposited for them, and the
danger of death from a ruptured artery ultimately is lost in
the gradual oncoming of inevitable cardiac cessation in
diastole. Thus we often see families where certain members
die at an early old age with apoplexy, while those who
survive to an advanced old age die of cardiac failure.
Apoplexy is the danger of the first stage of hypertrophied
heart and hardening arteries ; while death from heart failure
is the almost inevitable end of the more advanced condition.
Thus at first the more rigid arteries obstruct the flow of
blood, and the heart becomes hypertrophied ; but this com-
pensatory hyperplasia is not without risks, as consequence of
itself. The increased ventricular force may, and often does,
rupture one of the rigid arteries, and more especially if the
degeneration in the arterial coats be unequal, and one part
is less equal to the increased tension than another. Or it
may take place where the vessels are unusually thin- walled,
as in the brain, and so most readily give to the increased
tension; thus cerebral apoplexy is very commonly associated
with hypertrophied heart, as Rokitansky has shown. But
in time things alter, and the heart itself becomes the great
source of danger, and what the patient has gained on the one
hand he has lost on another. No doubt for a time that
cardiac impairment is undoubtedly preservative, but at length
it becomes itself the great source of danger. There is ever
danger, in time, of a compensatory process, preservative
though it be, becoming itself the great danger to life ; thus

158 THE HEART AND ITS DISEASES.

ill uroemia diarrhoea is compensatory and preservative, but
nevertheless it is not free fr-om danger.

The theory of compensation in morbid conditions has been
pushed by incautious advocates and rashly accepted by non-
thinkers till there is some risk at present of its being alto-
gether forgotten that morbid processes, and not physiological
actions, are being considered. Though the process may be
largely physiological, it must not be forgotten that is the
physiology of disease, if the expression may be permitted.
So fatty degeneration of the heart is, when combined with,
and probably taking its origin in, atheromatous arteries, a
distinctly preservative lesion, but it none the less becomes in
time the great diinger itself. Still it is, like all compensatory
actions, the substitution of a lesser evil for a greater. For if
the vessels, as they are found on death by cardiac failure,
had been all along subjected to the force of a normal heart,
a rupture must almost inevitably have occurred before the
date of the cardiac cessation. For the diminution of the
distending force has slowed the diseased action in those
arteries, and had those diseased arteries been all along sub-
jected to the same distending force, as induced the disease
originally, their decay must have been accelerated, and rup-
ture of them unavertible. Thus the gean by this preservative
action is unquestionable, at the same time we must admit
that it cannot be regarded as an unalloyed good. This de-
generative process in the circulatory system is of the greatest
interest to the profession, and a knowledge of the various
stages in it of the highest importance in our dealings with
persons of advanced life, when the maintenance of life is
becoming of great importance not only to the person, but to
society, from the ripened intellect. This change from hyper-
trophy to fatty degeneration so profoundly modifies and
alters the symptoms, that the varying signs and symptoms
will have to be considered in a later section at some length,
and in close connection with their pathological import, and
the morbid processes indicated by them. Hypertrophy when
not connected with altered arterial conditions, as in aortic
obstruction, will remain unaltered for years ; and the new
tissue does not have any inferior or defective vitality, in con-

DISEASES OF THE MUSCULAR WALLS. 159

sequence of which it soon undergoes degeneration ; the
degeneration is as physiological as the hypertrophy, and has
a similar, indeed an identical origin. This somewhat lengthy
discussion may, perhaps, be useful and excusable, as helping
to elucidate a subject, however familiar to some readers, not
yet fully understood by the bulk of the profession.

Fatty degeneration is at other times connected with
ossification of the coronary arteries. And it must be admitted
that in some cases the coronary circulation is found in an
extensively diseased condition, without the systemic circula-
tion being to any like extent affected. This is a subject well
worthy of being taken up by some youthful reader and care-
fully investigating. It is certainly a difficult subject, and as
yet shrouded in mystery. It would appear, however, that
the calibre of the first portion of the coronary arteries, and
the construction of the orifice, by which they are exposed to
unusual strain, offer an a priori probable clue. The coronary
circulation is not, however, itself always equally affected, and
some parts are more diseased than others, leading to more
and less advanced conditions of degeneration in the muscular
walls themselves. The coronary vessels are often obstructed
by growths of atheroma in tubercular masses at their orifice,
and sudden blocking by a dislodged mass is one cause of
sudden death by cardiac syncope.

Fatty degeneration, too, as connected with imperfect
blood supply, may arise from partial obliteration of the coro-
nary arteries by pericardial adhesion along or across them ;
for the sulci in which they run are not deep enough to com-
pletely protect them from this danger.

Where this degeneration is the result of disease, &c., of
the coronary vessels, it may be limited to the right or left
side according to the artery affected ; or even be more
localised when a branch is diseased or plugged by an em-
bolon.

Fatty degeneration is also one of the risks which dog car-
diac dilatation, for this imperfect arterial distension, produced
from feeble ventricular contraction, leads to imperfect arterial
recoil and impaired tissue nutrition. From these various
considerations we see that fatty degeneration of the heart is

160 THE HEART AND ITS DISEASES.

intimately associated with defective blood supply, and tliat
its course is acute, or chronic, in direct proportion to the dimi-
nution in the blood supply : where cut off abruptly, the
degeneration is rapid and pronounced; where a gradual
diminution has slowly been instituted, the degeneration is
more protracted.

There are, however, conditions which originate or induce
this musculai' degeneration, which are not intimately asso-
ciated with the amount of blood supply. This fatty degene-
ration of the heart has been found allied with a degenerative
condition of the lungs and kidneys, in which general degene-
rated condition the disease in each organ goes on hand in
hand with each other ; not, however, standing to each other
in the relation of cause and effect, but apparently each the
result of some general condition common to each as a pro-
voking cause. This compound state of visceral degeneration
has been described by Beale and Basham, and the latter in
his work on " Dropsy " gives some most interesting cases
illus.trative of it, and also by R. Virchow, who also found an
impaired and degenerate condition of the gastric mucous
lining to accompany it. It has been supposed that this de-
generation may be due to some defect in the trophic nerves
in these viscera, taking its rise in some impaired condition of
the organic system of nerves, some derangement in what
Bichat denominated the vegetative processes, but, as yet, this
is merely speculative.

The connection of fatty degeneration of the heart with
sclerosis of the cardiac ganglia, or other disease of them, is
merely presumed : the subject is no more than an inviting
field for original investigation.

There is still one more curious matter about this mus-
cular degeneration in relation to its causation, and which
throws a side light upon its patliology, and that is its rela-
tion to poisoning. Not only did E. Wagner find it in con-
nection with phosphorus poisoning, but it has also been found
in poisoning with other acids than phosphoric. Von Dusch
gives a list of sulphuric, nitric, phosphoric, oxalic, and tar-
taric acids, coupled with the names of Koch, Kokitansky,
Lewin, Tiingel, E. Wagner, Lowe, Mannkopf, Munk, and

DISEASES OF THE MUSCULAR WALLS. 161

Ley den. This curious association of it with poisoning by
acids is apparently somehow connected with the evolution of
nitrogen in the process of this fatty degeneration of albu-
minous compounds, as first observed by Michaelis. Whether
these acids when administered in excess, circulate in the
blood, and by depriving the nitrogenised tissues of their
ammonia, and thus leaving the other constituents as fat, or
not, we cannot tell. If this should be found to be the case,
it will increase the importance of the alkalinity of the blood,
as protecting the muscular tissues. The tissues are always
impaired in those deeply sceptic pyoemic conditions in which
Virchow found the blood positively acid. That in this con-
dition, as well as the poisoning by acids, the heart's structure
should be so deeply involved, is explained by its free blood
supply, as compared to other muscular structures, and not by
any peculiarity in itself.

From these considerations we can surmise that this fatty
degeneration is a histolytic process, variously instituted.
That it commences in the germinal matter, and spreads there-
from into the formed material, gives us some idea of its being
an arrest in nutritive processes, seen first where the pro-
cesses are conducted, and gradually found more and more
extensively as the formed material wears out, in the perform-
ance of its function, and is no longer perfectly renewed.
Further than this we cannot go, nor will any consideration
of the pathology, so far as yet known, aid us in any way in
affecting this morbid process therapeutically, except so far
as it is connected with the amount and nature of the blood
supply. Its relation, however, to anoemic or spanoemic con-
ditions is not yet proved to be such as to warrant any infer-
ence that it ordinarily, if ever, takes its origin in them.

Age. — The age at which this affection is most liable to
show itself is certainly that of advanced life ; the greatest
number of deaths from fatty degeneration occurring in any
one year is stated by Sir Thomas Watson to be in the 63rd
year. There is no doubt that it is a comparatively rare
affection in early life ; when it occurs then, it is almost
always in consequence of its accompanying some general
affection, or from pericardial adhesion. Its frequency in-

M

162 THE HEART AND ITS DISEASES.

creases in middle life, and attains its maximum at or about
the age fixed by Watson, its comparative frequency dimi-
nishing as the more advanced periods of old age are reached.
But in considering this question, it is not possible to speak
with any exactness, and an array of statistics would add
little to the importance to be attached to any more positive
statement. Many cases are obscured by other lesions, and
the majority of causes of death are not corroborated hj post
mortem examination.

Sex, — There is every reason to suppose that the male sex
are more liable to fatty degeneration of the heart than the
female sex, but not by any remarkable preponderance.
(Dr. Quain, however, calculates it as 5 to 2, males being much
more liable to it.) It would not be correct to suppose that
every member of the weaker sex who makes ostentatious
display of " a weak heart," is positively suffering from any
structural affection of the heart walls, even when occasional
attacks of anjina are present. But there is grave ground for
suspicion in those numerous cases, especially in those whose
lot does not subject them to exertion, for that would soon
test the truth, when at or near the menopause a lady is
noticed to be short of breath, blue about the lips, the coun-
tenance at times injected, vertigo, and syncope not unusual,
and induced by slight exertion, the feet cold, and the hands
white, puffy-looking, and pasty. The sounds of the heart
are thin but clear, and the pulse feeble and compressible, and
the amount of urine scanty, and laden with lithates. If, in
addition, the first sound is out of all proportion slight as com-
pared to the second sound, which, though not accentuated, is
clear and distinct ; if the first sound is almost lost, or merely
consists of tlie sound occasioned by the closure of the auri-
eulo-ventricular valves, there is grave ground, indeed, for
suspicion- But the numerous cases Avliere, after the critical
period has been passed, the symptoms vanish, demonstrate
that though these symptoms are serious, they may indicate
some other affection of the heart walls than this especial
form of degeneration of the muscular fibrilla3. This is some-
what a digression from the exact subject under consideration,
and yet it bears on, not exactly the comparative frequency

DISEASES OF THE MUSCULAR WALLS. 163

in the two sexes, but what we think in our experience is the
comparative frequency. It is very obvious that in the absence
of more general post mortem examination, this, as well as
some other matters of fact, will remain to a great extent a
matter of opinion.

Occupation, Sfc. — It is said that fatty degeneration is a
common affection among London gin-drinkers, and it has
certainly appeared to m.e a common complaint among elderly
publicans. How far, when so occurring, it is a consequence
of the constant existence on a hydro-carbonaceous food, for
many of these persons can scarcely be said to eat, which is
unsuited to repair of a constantly wearing out nitrogenised
tissue, or not, it is not possible to say with any certainty. It
is, perhaps, too, somewhat common among men whose pur-
suits entail very little or no bodily exercise, and it has been
stated to be a common cause of death to judges. How far
the position and power to obtain large amounts of rich food
without much bodily exertion, leads to an atheromatous con-
dition of the vessels, which in its turn entails a fatty degene-
ration of the heart, is the cause of this disease ; or how far
the respired oxygen is met and neutralised by the hydro-
carbons in the blood, and thus is not available for the removal
of worn out waste material, a necessary preliminary to the
growth of new tissue, are subjects yet uninvestigated. The
non-development of muscular tissue on a purely hydrocar-
bonaceous diet, and the imperfect removal of waste material
in those who live well and work little, must not be confounded
with the development of fat cells in the intermuscular tissue
(Neufettbildung), often associated with general development
of adipose tissue. General fatness is no protection against
fatty degeneration of the heart, but neither is extreme lean-
ness. These persons die as much from this degenerative
tissue-decay as do stout persons ; and it may be found in
persons of every position in life, from the millionaire to the
bricklayer's labourer.

Physical Signs. — The physical signs are more decidedly
negative than positive, for this degenerative decay is marked
not by positive manifestations, but by failure of ordinary

I manifestations ; the absence of action and power.
M 2

164 THE HEART AND ITS DISEASES.

Inspection. — There is nothing to inspection but the absence
of action, and even in those thin persons where normally a
movement over the apex-beat can be seen, especially with
the light falling on it, no movement is detectable.

Palpation. — On placing the hand over the heart no move-
ment is felt, if the degeneration has commenced in a heart
of normal size. But if, as not unfrequently happens, there
is degeneration setting in in a heart which has previously
been hypertrophied, there is the tumbling, rolling, irregular
action, very similar to a weak dilated heart, with a sensation
of diffusion, as if the apex were broadened ; indeed we know
that the process of dilatation goes on when hypertrophy is
yielding to this tissue-necrosis. Still, these positive symp-
toms are not associated with the fatty degeneration, but with
the hypertrophy. It may indeed be gravely questioned if
ever, even under the most probable circumstances, any
excited action be felt in a degenerate heart. There is no
more laborious action in the heart than there is its outward
visible sign palpitation ; instead of that there is almost total
abolition of action and syncope.

Percussion. — Neither is there increase of percussion dul-
ness. Dilatation of the degenerate heart is not a charac-
teristic of this form of disease. Where dilatation is most
usually found, is when hypertrophy has already existed and
is yielding. The degenerate heart not previously altered in
bulk or shape, does not usually become dilated : it may, how-
ever, do so. There is not then usually, or necessarily, any
increase in percussion dulness. Nor can any alteration in
the bulk of the heart be regarded as characteristic of fatty
degeneration ; neither diminution nor enlargement belong to
it in itself. It is highly questionable whether this structural
decay leads to any lessening of the heart's bulk, any atrophy
of it (though the diseases have been regarded as associated),
and thougli it is foiuid in hearts both hypertrophied and
dilated ; still neither of these changes can be considered to
be allied with it. Though dilatation will result from it in a
heart previously hypertrophied, and any change in shape in
an hypertrophied heart is significant, along with other in-
dications, still we are not entitled to regard dilatation as an

DISEASES OF THE MUSCULAR WALLS. 165

essential characteristic of fatty degeneration ; though it may
result from it both in normal as well as hypertrophied
hearts.

Auscultation, To the negative results furnished by palpa-
tion chiefly, we must add the negative and positive ones
yielded to auscultation. This last is our most trustworthy
guide in forming a diagnosis of fatty degeneration. The
first and most absolutely positive indication is diminution of
the first sound. The first sound may, in advanced cases, be
almost absolutely lost, and, in comparison with the second
sound, is inaudible. In less marked cases the first sound may
be very faint, and is obscure compared to the clear thin
second sound. When the first sound is, as it not uncommonly
is, almost entirely due to the closure of the auriculo-ventri-
cular valves, it is thin and clear, and much resembles the
second sound. In every case, indeed, the muscular sound is
impaired ; the muscular portion of the first sound is absent,
more or less completely. Thus the first sound wants its
ordinary duration, its chronicity as compared to the second
sound ; the heart's sounds are almost those of two second
sounds following each other. This loss of the first sound is
the most valuable single sign in connection with the disease
under consideration.

But when there has been previously existing hypertrophy
there may still exist a fair amount of muscular sound from
the amount of muscular fibre remaining healthy. Then it
comes to a question of comparison of sound with bulk and
shape, a question which must necessarily rest on each man's
individual experience, not, indeed, about it itself, but about
his power to appraise it. There is no more difficult diagnosis,
not even in abdominal tumours, than in this combination
of pre-existing hypertrophy and more recent degeneration.
The subjective and objective symptoms, the patient's history,
his failing power may throw some light on the complication
in the physical signs, but the progress of the case and re-
peated examination alone will decide it, and even then
allowances must be made for the possibility of temporary
improvement under remedies and suitable treatment.

The characteristic sign of fatty degeneration is impair-

166 THE HEART AND ITS DISEASES.

ment or loss of first sound ; a condition, however, which will
occur in elderly persons in anoemic states, and passes away
with the condition on which it causatively depends. Thus
loss of first sound must not merely be detected, but the ob-
servations must be repeated, and it must be found to be
persistent, then it is of the gravest import : but temporary
loss or impairment of first sound may be found along with
other conditions than that of structural degeneration of the
heart-walls.

Impairment of first sound is the characteristic of disease
of the muscular walls of the heart, and though most com-
monly found allied to fatty degeneration of them, for the
obvious reason that this is the most common affection, is also
found along with fatty interstitial infiltration, amyloid heart,
&c. Indeed the signs of fatty heart are shared by those
other conditions, which preserve both the signs, and, to some
extent, the symptoms of this affection.

Objective Symptoms. — These are not confined to the heart,
but extend to the arterial system ; and the changes formed
in the eye and skin may also correctly be classed under this
head.

Objective Symptoms in the Heart itself. — Firstly, we put
aside palpitation. Palpitation is not a symptom of disease
of the heart walls. The heart walls when diseased, and espe-
cially when degenerate, do not act laboriously ordinarily,
and consequently there is not palpitation. Palpitation is
rather the characteristic of distension and dilatation in a
heart structurally sound. The degenerate heart does not
give out this active witness of inability ; instead of that
there is syncope, more or less perfect. Positive acknowledg-
ment of inability is the characteristic of cardiac degenera-
tion. The sound heart may be distended and try to labour
so handicapped, but the structurally diseased heart will not
distend, but suffers almost complete cessation of action when
exposed to such action as would induce distension and palpi-
tation in a structurally sound but dilated heart. True, when
there is previous hypertrophy there is distension, and the
resumption of that dilating process, which hypertrophy
arrested, and, consequently, palpitation. Still, we are

DISEASES OF THE MUSCULAR WALLS. 167

entitled to regard palpitation as associated with an over-
distended or dilated heart, and not as associated with fatty
degeneration. It may occur in the complex condition of
hypertrophy undergoing degeneration and becoming dilated,
but it is with the dilatation of the sound fibres, not the decay
of the diseased ones that it is associated. Palpitation is the
characteristic of dilatation, syncope of structural degenera-
tion.

Irregularity. — Irregularity or arrested, delayed, ventricu-
lar systole is associated with structural degeneration as well
as other afiections of the heart, valvular or dilated condi-
tions. It is the irregularity occurring at intervals, a number
of normal beats, both in time and volume, and then a pause,
often preceded by two or three rapid beats. Or again, with
an undulating, feeble pulse, with prolonged halts, that is
very often met with in fatty degeneration. The irregularity
is increased by any effort, going upstairs, difficulty in empty-
ing the bowels, or the physical excitement often arising from
mental disturbance. The increase in amount of irregularity
on effort, or any call on the heart, is ever indicative of
organic disease. The effect of effort will always almost
settle the diagnosis betwixt the irregularity of organic
disease and those purely nervous disturbances so similar,
indeed identical, for a full and able explanation of which the
profession owes its thanks to B. W. Richardson. The effect
of effort will almost alone decide the question, without appeal
to the subjective symptoms, rarely or never absent in the one
case, and in no way associated with the other. In a dilated
heart with persistent irregularity, effort usually induces
palpitation as a temporary condition implanted on the per-
manent one ; be that dilatation connected with other con-
ditions as it may ; but in structural degeneration there are
more absolute evidences of failure of power. Instead of
palpitation, the irregularity is increased, and becomes more
marked, and the ominous halt of intermittency is rather
found than any such positive action as is implied by pal-
pitation.

Intermittency, — In fatty degeneration of the muscular
fibrillsB of the heart_, there are commonly found halts, more

168 THE HEART AND ITS DISEASES.

prolonged than is compatible with the term irregularity : the
pause is so pronounced as to establish its claim to the term
intermittency, i.e., there is intermittent action, a pause over
the period of one ventricular contraction. This may extend
over one or more auricular contractions,* and be more or less
pronounced. It may occur at almost rhythmical intervals,
the periods being shortened by effort or excitement. It has
been disputed whether during this pause the ventricle halted,
or whether a contraction took place too imperfect to produce
any perceptible effect on the radial pulse.

Personally, I am inclined to think that both conditions
occur, and in some cases on applying a stethoscope over the
heart, while the finger is kept on the radial pulse, during the
pauses a feeble ventricular contraction may be heard but not
felt. Nor is this surprising ! A feeble ventricular contraction,
and so perceptibly imperfect to the ear, would lose most of
its effect on the backward flow occurring before the auriculo-
ventricular valve is closed, and little even of its feeble im-
pulse be transmitted to the radial pulse. This view is corro-
borated by the character of the second sound, which is quite,
or all but, inaudible. There is reason for supposing that such
imperfect ventricular systole may occur as will leave no im-
pression on the radial artery. But the question is not a
practically important one. The prolonged ventricular halt
amidst the other evidences of failing power in the circulation
is ever prognosticahy grave, and when slight effort induces
this prolonged halt amidst the flutter of irregularity, its
presence is ever ominous. Sometimes this halt is found along
with an ordinarily slow pulse, a pulse not so quick as the
normal : indeed a rapid pulse is not characteristic of fatty
degeneration, but rather a moderately quiet, slow, feeble
pulse.

Not very rarely the lialt will come consecutively for
two beats or more, and then the rythm-of the heart is much
disturbed. Disturbance of rythm, by delay, combined with
loss of power, is almost characteristic of fatty degeneration,

* See a paper bj the writer in the Lancet of April 13th, 1872, on " Cardiac
Intormittency," for the evidence of this ventricular pauae over one or more
auricular contractions.

DISEASES OF THE MUSCULAR WALLS. 169

especially when associated with loss of first sound. When
so accompanied, disturbance of rythm is not nervous but
muscular, and the condition indicated not nervous disturb-
ance, but structural disease of the walls of the heart.

In the Arteries. — There is not necessarily atheroma of the
arteries, though it is usually present. The pulse is feeble,
compressible, unsustained, and easily obliterated by pressure.
It is the reflex of the heart, and the elastic arterial system
merely reflects the impression made on it. Thus the ventri-
cular contractions are repeated as received, a slight tardiness
in the arterial pulse being observable. When irregularity is
present in the heart's action, it is found in the pulse at the
wrist, and as fatty degeneration is associated with the heart
generally, and when localised not usually found in the right
ventricle, there is usually a corresponding irregularity _, and
not a more marked one to auscultation than to the finger on
the radial pulse. As, however, clinically, fatty heart and
atheromatous arteries go commonly together, there is usually
seen a tortuous temporal artery meandering away along a
temple wrinkled and bald Sometimes the artery is unusually
prominent and covered with a parchment-like tegument,
while the temples are either covered with grey hair, where
the hair is coarse and strong, or a few fine grey, silvery hairs
may be found far back, with a perfectly bald crown When
the arteries are atheromatous, a totally false impression of
strength may be communicated by the pulse to the finger,
and this falseness is detected in auscultating the heart.

The Eye. — Much discussion has taken place since E. Canton
first gave his opinion on the diagnostic value of the " Arcus
Senilis," as indicative of fatty degeneration of the heart. Its
importance, however, as an auxiliary to diagnosis, is now
generally admitted. Its presence alone is not suflicient to
warrant even the most elementary diagnosis. In fact, this
opaque ring at the union of the sclerotic and the cornea, is
not always truly fatty, in a degenerative sense. It may be
found as a clear, bluish ring, giving a peculiar expression to
an eye still bright and vivacious.

The owner of this eye may be old or elderly, but is active
in mind and body, and it is often found allied to unusually

170 THE HEART AND ITS DISEASES.

hale, active old age ; green old age, in fact, both mentally as
well as corporeally. This ring is not of bad prognostic im-
port. It is perhaps as much calcareous as fatty, and is
homologous with the osseous ring found normally here in the
bird.

But at other times this ring is found yellowish, with ill-
defined edges, with a dim eye, a somewhat tottering or
tremulous gait, and a muscular unsteadiness, and when so
associated, its prognostic as well as its diagnostic import is
widely different. When this ring is indistinct about its edges,
and gradually melts away into a cloudy cornea, it is patho-
gnomonic of degenerative changes. The cloudiness of cornea
is due to the presence of globules of fat scattered throughout
its substance, to real degeneration of structure, and this
cloudiness gives the dim look to the eye, and often a doubt-
ful, wavering expression, Avhich is heightened by the hesitating
manner and muscular unsteadiness. This eye is never, per-
haps absolutely never, found without a shaky pulse, a feeble
heart, and great evidence of general decadence. The import-
ance of this objective symptom must not be underrated, as it
frequently attracts attention to the general condition, which
might otherwise not be evoked by the patient's appearance
or complaints. But the two forms of arcus senilis must not
be forgotten.

The Skin. — A field is open here to some exact chnical ob-
servations, combined with microscopical observation. The
skin in many cases of cardiac degeneration is distinctly
altered to the naked eye. The appearance sometimes is that
of discoloured parchment, while at other times the epidermis
looks thick, opaque, and dull, there is none of the glistening
which is not altogether wanting in the healthy skin, even of
the aged. It is not the dry, harsh skin of mania, or even of
chronic Bright's disease, where the obstructed circulation,
through the thickened arterioles, leads to a dry, hard, un-
elastic skin. At other times the skin is greasy to the feel
like leather, or the outside of a bladder of lard, and the
epidermal cells rub off, looking fatty and degenerate.

Along with Dr. Clifford Allbutt, the writer often observed
these changes in the skin in patients, furnishing evidence of

DISEASES OF THE MUSCULAR WALLS. 171

degenerative changes in the viscera, and especially in those
sufifering from fatty degeneration of the heart. There is,
however, opportunity for more exact observations than those
we made, which were confined to the naked eye appearances
and to the sensations elicited by touch. The degenerative
processes extended to the hair which, if fine and silken,
usually dies of necrosis, or only a thin fringe extends from
the temples round the occiput. When it is naturally strong
and coarse it remains, and though '^ a hoary head is a crown
of glory," if the working of it be what it should be, still we
find that there is a degenerative process going on in it, allied
to that going on in degenerate heart fibres, that is, that the
loss of colour is due to the collecting of the pigment in
small masses, which can be seen under the microscope along
the axis of the hair.

Subjective Symptoms, — The subjective symptoms of fatty
degeneration are pronounced and positive, and present in the
great majority of cases. They consist of breathlessness,
syncope, angina pectoris, cerebral anoemia, muscular tremu-
lousness, impaired mental action, &c.

Breathlessness is most commonly and certainly present.
It differs from the difficult respiration of cardiac asthma, or
pulmonary congestion with dilated right ventricle. It is
shallow, hurried, without effort, while the face is pale, free
from congestion, and has a look of wild alarm very often ; in
cardiac dyspnoea there is heavy, imperfect, laborious breath-
ing, often with bronchial whistling, or moist rales, and the
countenance is injected, the lips blue, and the stamp on the
features is that of physical distress.

Syncope. — This is commonly found during the course of
fatty degeneration, and is induced by effort. When a sudden
effort or exertion is made, an obstruction is offered to the
flow of blood, the call upon the impaired heart is increased,
and its inability reveals itself in syncope. This sudden heart
failure is characteristic, and differs from the sudden death
merely in degree. Death is prolonged syncope, or may be
rupture.

This syncope, and even death, is not uncommonly met
with in elderly persons who long have felt themselves less

172 THE HEART AND ITS DISEASES.

equal to exertion, but, with that disinclination to Ihink them-
selves failing in power, let alone making mention of it to any
one, which characterises the oncome of age, ha;Ve thought
as little as possible of it, when some sudden exertion is ven-
tured upon. Thus hurry to catch a train, or even more, haste
to catch an omnibus, with the anxiety, as a stimulus to exer-
tion, increased by its visible propinquity, and not rarely by
the conductor who will allow it to move on a short way in
order to give the lagging would-be passenger a lesson, not
uncommonly induce an effort which results in most distressing
faintness and general uneasiness, sometimes lasting for hours
or even in sudden death.

There is some reason for thinking that some effort usually
precedes those sudden deaths, without apparent exciting
cause^ but of course there is no means of interrogating the
dead, or eliciting the facts. But sudden failure does not
arise spontaneously usually : if all the circumstances could
be ascertained, some exciting cause, may be a comparatively
trifling one, would be elicited. Effort on the night-chair
notoriously produces alarming faintness, and not rarely
sudden death. The sudden assumption of the erect posture,
by throwing the weight of the column of blood in the ascend-
ing aorta and carotids, &c., in the enfeebled heart, will also
produce both temporary and persistent syncope.

Angina Pectoris. — This symptom was long considered
pathognomonic of fatty degeneration. It is not so however,
though it is, as a symptom, often so associated. Angina
pectoris may, like the true objective symptoms in the heart,
be either nervous derangement, or associated with structural
histo-necrosis. The two forms of angina are closely similar
if not identical, in their symptomatology, and the general
collateral symptoms and signs must be called in to establish
the diagnosis. As, however, angina pectoris will be con-
sidered separately, as a nervous affection, it is not necessary
here to do more than give it as found when accompanying
fatty degeneration.

The attack is usually sudden, the chest seems held in a
vice, the breathing becomes shallow, not laboured, muscular
power seems paralysed, the features become stamped with a

DISEASES OF THE MUSCULAR WALLS. 173

combination of alarm and horror, the face is pale, and down
the brow roll large bead-like drops of perspiration, and the
voice becomes weak and importunate. There is, or is not,
pain in the chest, though usually there is that sickening pain
which is received through the sympathetic, when an impres-
sion on it is powerful enough to produce pain. The patient's
condition excites the greatest alarm and sympathy in on-
lookers, who, no less than the patient, are apprehensive of
instant dissolution occurring. This condition may recur
several times, or the first may be fatal. After it the patient
is left prostrate, shaken, and unnerved for some time. If the
attack be nervous, in a day or two at any rate, the heart
sounds will be found normal and good, when it is connected
with fatty degeneration there is feeble impulse, loss of first
sound, &c., &c. W. T. Gau-diner has described a form of
angina sine dolor e, in which all the symptoms are present,
except pain, which is not essential to it. This angina pec-
toris must be discriminated from the attacks of cardiac
dyspnoea, which are somewhat similar, and have been termed
false angina pectoris. Cardiac dyspnoea is usually accompanied
by injected countenance, the absence of the bead-like drops of
sweat, though they may be present, blue lips, all the evidences
indeed of passing cyanosis, while the respiration is laborious,
obviously and evidently connected with effort, and there are
chest rales and other evidences to the stethoscope of pul-
monary congestion, as loud, harsh respiration, &c., and the
assumption by the patient of the sitting posture even when
in bed. The diagnosis of it, and that form of cardiac apnoea
which is associated with spasm of the pulmonic arterioles
and thus arrest of respiration is more complicated, but in
this latter there is also cyanosis and right side distension,
&c. The diagnosis betwixt angina and asthma need not be
described. In all these cases the pulse is feeble, irregular,
and almost imperceptible. But in angina the heart sounds
are equally feeble and the apex beat undetectable, while in
those cases where the obstruction in the lungs leads to right
side distension, there is palpitation, as the evidence of
laboriousness, in the right heart : indeed, Hope says that
the most violent palpitation is often found when the right

174 THE HEART AND ITS DISEASES.

ventricle is distended almost to paralysis in aggravated car-
diac dyspnoea. In angina pectoris, there is no action of the
auxiliary muscles of respiration, which are always in great,
and even violent, action in the other forms of disease with
which it may be confounded. In the other forms there is
obvious difficulty in breathing : in angina pectoris there is
rather an abolition of the act. The pathology of angina will
be given in the section on it in Chapter XII.

There is not in fatty degeneration the oppression in the
chest, the sensation of labouring, which occurs in other cases
where disturbance of respiration is associated with other
heart affections. There is rather an avoidance of effort, an
instinctive spontaneous shirking from effort in fatty degene-
ration, than the voluntary intelligent avoidance of effort, 'in
consequence of the difficult respiration it induces, as expe-
rience has taught the patient, which is the cause of quiet in
the other forms of heart disease.

Cerebral Anaemia, — This is a condition which is frequently
associated with disease of the heart, and therefore with fatty
degeneration. The imperfect circulation deprives the brain
of its supply of arterial blood, and the chronic imperfect
supply may cause a condition of chronic cerebral anoemia. It
may, however, be subject to occasional acute exacerbations,
much resembling an apoplectic form of attack. There is loss
of consciousness and muscular power, somewhat more sudden
than the more gradual oncome of apoplexy ; there is a small,
slow pulse, with unfilled arteries, and cold, pale skin. This
condition may persist for some hours even, and longer. In
speaking of anoemic conditions of the brain, Todd, in his
Cyclopaedia of Anatomy and Physiology, article " Abnormal
Anatomy of Nerve-Centres," says, " It (aenoemia) is also pre-
sent when- the heart, oppressed by some disease affecting its
own structure, fails to propel the blood with its proper force
into the brain." This effect upon the brain, of inability in
the heart, produces not merely physical, but psychical mani-
festations even. B. W. Richardson, in his " Discourses on
Practical Physic," (1871), article on *' Intermittent Pulse and
Palpitation," says, " The man or woman with a hesitating
heart is thereby unfitted for sudden tasks, demands, resolves,

DISEASES OF THE MUSCULAR WALLS. 175

which, when the heart is firm, are considered as of compara-
tively Httle moment, for when the heart hesitates, the brain,
which reposes for its power on the blood the heart supplies
to it, falters with the heart, just as the gas flickers when
the steady pressure is taken off the main. From these cir-
cumstances some persons, who once were known as resolute
and determined, lose those qualities when they are subjected
to intermittent action of the heart, becoming, as their friends
say, uncertain and doubtful in character, becoming, as they
themselves feel and know, less the masters of themselves,
and less secure in their own work, and skill, and power."
There is no doubt about the truthfulness of this picture,
drawn, as it is, by a master hand.

The cerebral anoemia which accompanies fatty degenera-
tion of the heart, has attracted attention in consequence of
a peculiar effect upon respiration induced by it, called ^' the
phenomenon of Cheyne." This accomplished Dublin phy-
sician first observed a peculiar ebb and flow in the respiration,
a dying away of the respiration, till it became apparently
lost, and then a gradual deepening of it again, till one or
two deep respirations passed, and then a gradual fading
away of it. This symptom has been noticed elsewhere, and
need only be mentioned here in order that its diagnostic
value may be given. It is not peculiar to fatty degeneration,
and von Dusch has noticed it in tumours of the brain, in
basilar-meningitis, in uraemic coma, and in a grave attack of
pericarditis. It first struck the writer forcibly in a case of
genuine apoplexy, and next in the venous congestion and
sopor of primary tricuscipid regurgitation.

Muscular Tremulousness, — This imperfect supply of blood
to the brain affects the muscular system generally, and gives
an uncertainty to the step, and a tottering appearance to the
gait, while sudden exacerbations occur, when the beat falters
more than usual, in which the patient is seized by a sudden
feeling of loss of power, and snatches convulsively at the
nearest object, tree, or lamp-post, companion, or stair-rail.
This sudden convulsive snatching is momentary, and passes
off as quickly as it came, but the general enfeebled muscular
Dower is persistent. There is a peculiar expression in the

176 THE HEART AND ITS DISEASES.

gait of the person with cerebral anoemia from fatty heart, a
sort of guarded, quiet, distrustful walk, an avoidance of shocks
or effort, combined with evident unsteadiness ; there is a
want of firmness in the step and tread, corresponding to
what Dr. Richardson has said of the mind, which distin-
guishes it from the other gaits produced by cerebral or
spinal degeneration. There is no irregularity, no loss of co-
ordinating power, no jerking of limbs, neither is there trailing
of them, or inability to hft them, nor yet the faltering step
and disarranged toilet, so characteristic of certain nervous
diseases. There is no paralysis of the sphincters, nor trouble
with the bladder. Indeed from lessened arterial tension the
urine is scanty, and usually laden with lithates.

History, — The history of fatty degeneration is in the very
great majority of instances insidious and unmarked, at other
times some peculiar occurrence or accident may have elicited
the fact of its presence, and not uncommonly that occurrence
is a visit to an insurance examiner. The discovery of fatty
degeneration is often some personally unpleasing incident,
often, however, a private discovery of the patient's, and kept
carefully to himself witli great secretive reticence. The
appearance and condition of a person with fatty degeneration
is somewhat difficult to describe, and instead of attempting
to give exact clinical cases, a description of some various
typical forms may neither be uninteresting or uninstructive.
A case of moderately decided heart degeneration presents
somewhat the following sigiLS and symptoms. The patient
is at or over middle age, with a comfortable enjoyment ot
existence, when at rest, with quiet pulse and respiration, and
an appearance of fair health. But exertion is instinctively
avoided, and his locomotion is evidently connected with
exertion, all excitement is avoided, or, in excitable tempera-
ments, found to disagree. The pulse becomes irregular on
exertion, and the respiration is hurried, but not laboured.
The heart-sounds on auscultation are feeble, and there is
loss of proportion betwixt the first and second sound.

A more advanced case will present rather this appearance :
an anxious or uneasy-looking face, with dim eye, discoloured
or dull skin, and a tortuous temporal artery, with a bald or

DISEASES OF THE MUSCULAR WALLS. 177

grey head, great breatlilessness, and inability for exertion ; a
pulse small, irregular, and with frequent halts, or sometimes
a pulse rather as a fluttering undulation, difficult locomotion,
and impaired or enfeebled intellect. The heart sounds are
those of two second sounds, or the first may be entirely
inaudible. There is cough, and somewhat of expectora-
tion, but it is not bronchitis, nor yet the free expectora-
tion when the bronchial veins partake of the general venous
congestion, but rather a sort of degeneration of the bronchial
mucous membrane. There is often a querulous and petulant
voice, and a childish impatience and irritability. The patient
will be noticed when walking to pant and look distressed,
frequently to rest, either sitting down, or leaning against a
lamp-post or other support. By avoidance of efl'ort, this
condition is compatible with a longer continuation of life
than might at first sight seem possible.

Another case will appear somewhat thus. A pallid coun-
tenance, a look of wornout-ness, breatlilessness, small, indeed
tiny pulse, or exaggerated by an atheromatous condition of the
arteries, loss of appetite, loss of all sexual desire, general
debility, and indeed, premature old age. There are urine
tube casts, with fatty globules in them, loss of heart sounds
and impulse, rapidly increasing emphysema from degenerate
lungs ; an appearance, indeed, of ripeness, of ripeness merg-
ing into rottenness, a widespread, molecular necrosis, the
precursor of general somatic death. This condition has been
described by different writers, and is, if not the condition,
closely allied to the condition, denominated and described by
Sir Henry Halford, as '• climacteric decay." The subjects of
it are somewhat advanced in years, but their decay is in
advance of their years.

This affection, fatty histo-necrosis, occurs in connection
with hypertrophy which is giving way and presents some-
what the following condition and symptoms : —

A person advanced in years feels less equal to exer-
tion than before ; he has attacks of difficulty of breathing,
with palpitation easily induced, is more liable to feel
indigestion, &c. His pulse is moderately full, but somewhat

I irregular, and it is compressible out of proportion to its
!

178 THE HEART AND ITS DISEASES.

strength. The heai't is found hypertrophied and dilated,
with a tumultuous action felt over a considerable portion of
the chest wall, but there is a disproportion betwixt the
heart's impulse and the radial pulse, which is suggestive.

It is obvious that here a difficulty in diagnosis may arise.
Is the condition of the heart due to hypertrophy undergoing
degeneration ? Or is it due to dilatation not yet surrounded
by hypertrophy? As far perhaps as the condition of the
heart is perceptible to us, it is equally possible that the
tunmltuous action, with comparatively feeble compressible
pulse, may be due to either. The history, however, does not
point to a past history of inability for exertion, palpitation,
dyspnoea, &c., being recovered from, or being relieved of late,
but a consciousness of ever-increasing inability, growing from
day to day, a condition each day or week worse than before ;
this will aid to settle the diagnosis. If not established, a
little time will clear it up. If it is dilatation, not yet hyper-
trophied, but undergoing the process, improvement will be
found, and decided improvement, especially if a suitable
treatment be adopted. But if it is hypertrophy undergoing
this histo-necrosis, a slight alleviation may result from treat-
ment for a little time, but soon the downward process is
again in obvious action. The condition in a comparatively
brief time will be found somewhat so. The patient is breath-
less, liable to attacks of dyspnoea, which now call out the
muscles of forced respiration, and are accompanied by
lividity of countenance ; he is less equal to exertion than
ever. His pulse is more irregular and inclined to halt, much
aggravated by any slight effort ; his sleep is disturbed, and
his legs are puffy. His heart's sounds are less distinct, the
first being weak and short, the second clear and distinct, and
the normal proportion betwixt them is quite lost ; the heart's
action is more tumultuous, rolling, and unrythmical. His
whole condition is growing hopeless, and death may be
sudden, or life may continue till the symptoms common to
the later stages of heart disease are reached ; and venous
congestion has enfeebled every organ, from his kidneys to
his bronchial mucous membranes, and the sufferings from
this venous congestion are added to the original troubles.

DISEASES OF THE MUSCULAR WALLS. 179

Progress and Terminations. — The tendency of this fatty
degeneration of the muscular fibrillee is certainly to advance.
Depending as it mostly does on a g]'adually diminishing
blood supply, or on some defect in the fine processes of
vegetative life, whose presence can only be suspected,
''detected like a subtle odour" rather than demonstrated, its
tendency is to advance in the downward direction. This
molecular-necrosis of the structure of the heart is an insi-
dious decay, for which neither nature or art possess a remedy.
The progress is continued until the circulation is diminished
and obstructed, as much as it can be by any valvuJar disease,
unless the patient be cut off by sudden death. This is very
liable to occur from fatal syncope. Dr. Quain states that,
" out of 68 cases, death occurred in 21 by syncope lethalis "
(Lancet, " Lumleian Lectures," April 6, 1872). This is a
proportion of nearly one-third. That this proportion should
be so high can furnish no surprise, when we remember the
lessons of the dead-house and the advanced state of disease
in which hearts are found, where the patient had died of
some other affection. This syncope is usually associated
with some effort, not immediately at the time, but some
short time, hours or so, before. Some families are more
liable to die of syncope from fatty degeneration than others,
and most unquestionably men are more liable to it than
women. It is in women that the most prolonged and pain-
ful cases can and do take place. Many cases in men are
distressing and prolonged enough, but in women there is
often a pertinacious, even cat-like, tenacity to life, till every
painful sequel of heart disease is reached, and death takes
place from carbonic acid poisoning. Sudden death is a
merciful provision in heart disease, however appalling it may
appear to those in health and strength, and is often the
sincere hope of the patient, who indeed feels the troubles
more than the human frame can bear. But it is not so com-
mon certainly after the stage of positive invalidism is
reached. While the patient is still able to move about,
sudden death may be induced by effort, or may occur from a
heavy supper, but after the disease has progressed until all
exertion is physically impossible, sudden death is not so

N 2

180 THE HEART AND ITS DISEASES.

liable ; and, when it does occur, will be found associated
with some species of effort, as emptying the bowels, chang-
ing the linen, or even moving the position in bed. A gradual
general quiescence has ceased to tax the heart by sudden
calls on it, and a general lowering approximating the condi-
tion of the heart permits of life being still maintained ; con-
sequently the condition gradually grows worse ; the oedema,
once confined to the ankles, creeps up to the knees into the
thighs and external organs of generation ; there is oedema
of the lungs and eifusion into tlie pleural sacs and pericar-
dium ; there is ascites ; the amount of urine is greatly
diminished, and the urine is intensely acid, laden with
lithates, and growing albuminous ; there is venous conges-
tion of the contents of the encephalon, and coma ; or, from
this source, is added to the symptoms irritability, whimsical-
ness, and puerility, occasioned by inefficient supply of arterial
blood ; there are dreams at night, hideous and even worse
than the waking troubles. Then comes on carbonic acid
poisoning from defective oxidation, through the clogging of
the bronchiae by effusion from the bronchial veins,* the
patient nods off in a doze, which is not true sleep, wakens
with a start from a horrible dream ; dreading these dreams,
he tries to keep awake, but soon again drops off, and then
the case wears on till death comes to the relief.

It is possible that where this tissue-decay has been asso-
ciated with a diet too exclusively hydro-carbonaceous, and
containing too little nitrogen for tissue nutrition, that a
different diet with proper remedial measures may lead to an
improved histo-genesis and improvement ; but it is to be
feared these cases are exceedingly rare, unfortunately too
rare to affect the prognosis.

Prognosis. — From the pathology little can be expected
but the gloomiest prognosis as to the ultimate result. The
prognosis as to time may vary, and may contain some small
ground for hope. But life is terribly insecure. Fatal syncope

* My friend, R. Shirra Gibb, first pointed out to me in Vienna the error of
Eindflc'iseli and others in supposing the increased broncliial mueus to come
from tlie congestion of the lungs, tliis is anatomically impossible; it comes from
the bronchial reins which partake in the general venous congestion.

DISEASES OF THE MUSCULAR WALLS. 181

or rupture may be easily induced, may occur at any time, as
long as effort may induce them. The inevitable end may be
yet in the distance, but it is distinct enough. In forming a
prognosis the diagnosis must first be carefully made and
verified by several observations in the earlier cases ; and
only after repeated and careful examination should the
prognosis be delivered. In the more advanced stages of
disease the prognosis is less difficult ; but if the patient be
only then seen for the first time, caution is necessary. The
astonishing manner in which sufferers from heart disease,
with an advanced condition of dropsical and other sequelae,
will sometimes rally for a time, and thus sadly disturb a too
confident prognosis, without, of course, ultimately disproving
it, is somewhat startling.

Treatment. — There are points in connection with fatty de-
generation of the walls of the heart which justify some
special allusion to them, in addition to the chapter on Treat-
ment. The first question is as to the possibility of inducing
absorption of this fatty histolytic material. Remembering
that the lymphatics do absorb material no longer functionally
useful, and that this is subjected to a secondary digestion, a
fact insisted on in all works on physiology, it would seem
consistent with tliis knowledge to prescribe iodide of potas-
sium. But granting that the old matter is absorbed by this,
and it is not even probable, is there any ground for sup-
posing that in so doing any good is attained towards the
endowment of the germinal matter with power to furnish
competent histo-genesis ?

Without this, any removal of the old material, even if
possible, could only be futile, as regards any useful result.
The association of the disease with the germinal spots in the
early stages, and not with the portions of fibre more remote
from them, points to its connection with defect in tissue pro-
duction, rather than the non-removal of waste.

Whether any agent could be found which could affect this
defective histo-genesis, or not, is problematical. The general
rules of therapeutics for tissue-building, such as improvement
in the condition of the blood, aiding in its depuration by
arsenic^ iodide of potassium, and climinants generally ; and the

182 THE HEART AND ITS DISEASES.

improvement in it positively by the addition of iron, cod-liver
oil, not inadmissible here (as it would be in obesitas cordis, or
fatty infiltration), good, nutritious diet, with fresh air, and
carriage exercise, may be of some service. In those cases of
a \dcious alcoholic diet too long persisted in, good results
may fairly be expected to accrue, to a greater or less extent
from this treatment, and it has its advocates ; but it is in those
cases chiefly that it can do any good, while there is room for
suspicion that in many cases an error in diagnosis has been
made, and that condition, which in its signs and symptoms
simulates closely fatty degeneration, viz., an anoemic condi-
tion in the old or aged, alone exists, and is remedied by
appropriate treatment. No such suspicion, however, could
attach to the observations of Dr. Warburton Begbie who, in
his lectures, used to speak favourably of this curative treat-
ment by diet in many cases of fatty degenera tion. But there
is not much ground for hope in the direction of any treatment
other than palliative.

The palliative treatment of structural diseases of the
heart, whether existing alone, or allied to valvular lesions,
and they are not incompatible by any means, especially in
the more advanced stages of valvular lesions, is that from
which most must be expected. And the first point to be
insisted on is the avoidance of effort. If caught in a thunder-
storm, away from shelter, the patient must prefer getting
wet to the skin, with the inconvenience of going to bed till
his clothes dry, if change is not at hand ; if any accident
occurs he must avoid all interference, the shock is quite
deleterious enough for him ; he must avoid bustle and crowds,
must be in time for trains and omnibuses, &c., and must pre-
fer to miss them to making efibrts, which may be fatal. He
must regulate his bowels, and not strain at stool; sexual
intercourse is not free from danger, thougli the passion is too
diminished to make it a source of probable danger; still, if
found along with commencing locomotor artery, it is not a
mere hypothetical source of danger. He must avoid mental
excitement, politics, crowded meetings, where the atmosphere
befouled with carbonic acid, might produce dangerous faint-
ing ; and blood laden with carbonic acid not only partially

DISEASES OF THE MUSCULAR WALLS. 183

anassthetises the heart, but makes the blood flow less easily
along the blood-vessels (Wm. Henderson, Edin.). All mone-
tary speculations must be abandoned ; the excitement is not
free from danger, while the brain, imperfectly supplied with
arterial blood, is liable to erroneous calculations, to imperfect
thought, and is no longer suited to complicated mental pro-
cesses.

The patient's family must also be apprised that the cerebral
working is impaired, and petulance, perversity, puerile or
childish mental obliquity must be attributed to the physical
disease : indeed, more charity must be extended to the mental
processes of the aged, who no doubt ought all to be Nestors,
but are not, a condition not confined to the councillors of Job^
but found even in more recent times.

The patient's whole hfe must assume the character of the
invalid, and as the disease in the heart walls is not to be
remedied, a general lowering, or " levelling down," must be
insisted upon until a point is reached where the general
manifestations are more on a par with the condition of the
heart, and a species of equilibrium attained^ a balancing of
various parts in power, which is most favourable to the con-
tinuance of life. The preservative agency of lowered vitality
is a most important matter to bear in mind in the treatment
of incurable disease.*

This general maintenance of a quiet invalid's existence, in
the more advanced stages, and of avoidance of effort and
exertion in the less pronounced cases, may be somewhat
aided by action on the fibres of the heart, remaining sound,
by digitalis. Dr. Qnain (Lum. Lect.) endorses my sugges-
tion, made in Digitalis, to strengthen such fibres as remain
by the administration of digitalis. By avoidance of all call
upon the heart, by proper hygienic measures and attention
to secretions, and with this more especial treatment, he says,
" many cases will improve considerably." Considering Dr.
Quain's attention to this disease, his reputation and his con-
sequent extended experience, this statement is very encourag-

* A paper to this effect was read by the author at the Newcastle Annual
Meeting of the British Medical Association in 1872, and produced a lively dis-
cussion, in which Professor Hughes Bennett and others took part.

184 THE HEART AND ITS DISEASES.

ing. There is one encouragement, however, not intended
by it, and that is a too great confidence in our remedial
powers, for he also states, " In treatment we must bear in
mind the cause of the affection," and divides the cases into
those depending on a general state, and those where it is
rather a local condition.

Of course where there is yielding of the ventricular walls,
with venous congestion, &c., the administration of digitalis
may be of service, but it is by its effect on the sound fibres
which are yielding, and not by any action over the decayed
portions. The dilatation, and such symptoms and conse-
quences as arise from it, may be somewhat relieved by this
agent, but it is obvious that such a condition is not favour-
able to the action of any remedy ; and when dilatation, and
its sequelae, follow fatty degeneration, the comparative failure
of digitalis, or anything else, can be no matter of surprise.
The same must be said of all structural diseases of the heai*t,
as compared to simple dilatation in a structurally healthy
heart, and the apparent failure in the action of the remedy,
which, of course, is not a panacea for all heart disease, may
occasionally lie in the imperfection of the diagnosis, rather
than in the agent.

The treatment of the attacks of angina pectoris is noto-
riously unsatisfactory, and diffusible stimulants of all kinds
are administered. The addition of digitalis has appeared to the
writer as useful in these cases ; and where there is reason to
surmise it due to temporary distension, this is explicable. But
the variously described pathology of angina, for no more posi-
tive statement is yet warranted, makes all treatment empirical.
Brunton tried nitrate of amyl successfully, but Horatio
Wood, M.D., in the Warren Prize,* failed to satisfy himself,
by experiment, that we yet knew enough of nitrate of amyl
to indicate its therapeutical usefulness. Allowing the patient
to remain perfectly undisturbed, unless the position is posi-
tively injurious, is always advisable.

The other structural diseases of the heart arc diseases
connected with the muscular walls, but not with the muscu-
lar fibrillto themselves directly. The muscular structure

* "American Monthly Journal of Medical Scieneo," Julj, 1871.

DISEASES OF THE MUSCULAR WALLS. 185

sufters as a secondary affection as the result of compression,
but there is no disease within the sarcolemma. The disease
is essentially in the interstitial connective tissue, a cell growth
in the intermuscular areolar tissue.

Fatty Infiltration. — Here there is, as shown in Rindfleisch's
plate, a growth of fat in the intermuscular structure which
becomes destructive by its pressure on the muscular fibrillae.
These are seen to be compressed, diminished, and ultimately
destroyed. In proportion as this goes on the heart becomes
weaker and less efficient^ and the symptoms of organic heart
disease call the patient's attention to his own condition.
The deposit of fat, not uncommonly called obesitas cordis, is
not always scattered tbrough the structure to the heart, but
may arise from the fat which normally occupies the sub-
serous, or sub-peritoneal tissue, and covers the heart. When
so occurring, it proceeds gradually inwards and advances
along the connective tissue, compressing and destroying all
within its reach, as is the wont of interstitial affections. In
time the heart is found to consist of a mass of sub-serous
fat of a definite thickness, so that where the muscular struc-
ture is thick a considerable amount yet remains, as in the
left ventricle, wliile the right ventricle contains only a thin
layer of muscular fibre immediately under the endocardium,
with the columnse carnese and papillary muscles. At other
times it is not so especially connected with the outer surface
of the heart, but is more scattered.

The symptoms of this affection are those of impaired
action of the heart without valve-failure. The usual symp-
toms of hurried respiration, feeble, faltering pulse, and di-
minished first sound are found, just as in fatty degeneration
of the muscular fibrillae. The diagnosis is not easy, but the
points to remember are, that with this increase in fat comes
increase in bulk and in percussion-dulness, while this de-
velopment of fat accompanies general obesity, especially
when it sets in in elderly persons. There is rather cardiac
dyspnoea than angina pectoris, and the patient does not
present those degenerative changes which accompany the
tissue-necrosis. In the one there is evidence of good assimi-
lation and deposit of fat ; the other, though not necessarily

186 THE HEART AND ITS DISEASES.

a lean person, gives not this impression, but rather that of
impaired tissue-formation and repair.

Diagnosis. — In forming a diagnosis, there must be a sort
of calculation of probabilities, guided by any chance light
which may be thrown on the case by its own peculiarities.
But the distinction between fatty degeneration of the mus-
cular structure of the heart (Fettenartung) and fatty deposit
or infiltration (Fettneubildung) is rather pathological than
clinical. It is but proper, however, that they be considered
separately, being, as they are, two' such clearly distinct
diseases. Many cases of fatty tissue-decay are too marked
for any doubt, and in other cases the probability of fatty
deposit is so strong as to leave small room for doubt. The
difficulty would lie in cases of cardiac debility in persons of
full habit, and with a marked development of fat. But it
would not practically be of much importance to establish a
diagnosis, as the lines of treatment would be the same.

Prognosis. — The difference would lie a good deal in the
prognosis, which is better in fatty infiltration, as admitting,
as a possibility, of curative measures. Still, where much of
the muscular structure is destroyed, it is questionable how
far it could be repaired by new growtli.

Treatment. — Under either circumstances, supposing it
were possible to diagnose them perfectly, the treatment
would be directed to the development of nitrogenized tissue,
and the removal of fat. The use of alkaline waters, Vichy,
Seltzer, Carlsbad, Kissingen, Homburg, either on the spot or
in bottle, or a visit to British alkaline springs may be of
great use. There can exist no doubt that alkalies do tend
to break down the accumulation of fat within the body.
Small doses of iodide of potassium, along with fifteen or
twenty grain doses of bicarbonate of potash, three or four
times daily, may be used for patients who prefer it to the
use of mineral waters. But each dose should be accompanied
by a full draught of water after it : the dihition of alkalies
has a great deal to do with their being effective, let the pur-
pose for which they are administered be what it may. Also,
no doubt, hydrocarbons should l)e taken but sparingly, and
more especially in the concentrated forms of fats, oils, butter,

DISEASES OF THE MUSCULAR WALLS. 187

&c. Perhaps, however, sugar is as objectionable as any-
thing, not only for its ready assimilation, but its tendency to
aid in the assimilation of other hydrocarbons. The entire
deprival, as far as is possible, of hydrocarbons and the sub-
stitution for them of an unlimited supply of nitrogenized
food, commonly known as the system of Banting^ is a dan-
gerous liberty with man's construction, as not being entirely
a carnivorous animal. The attempt to procure this sudden
metamorphosis is about as likely to be successful as would
be an attempt to procure an equally marked variation of
type in support of Darwin's views. No doubt certain tribes
have become from necessity almost entirely meat-eaters,
and an hereditary transmission of the power to feed on it,
implied by survivorship, may enable them to do so with
comparative impunity ; but it cannot be supposed that a
medical consultation, or the perusal of a pamphlet, can effect
this accommodation. The deprivation of hydrocarbons gives
a craving for alcohol, let the explanation be what it may :
and the Indian and the hunter do not abandon themselves to
debauches from sheer depravity, and a course of Bantingism
produces similar inclinations. Beer and porter are not only
alcoholic, but are largely charged with sugar, called in
brewer's phrase " saccharine," and are decidedly to be with-
drawn from the patient with obesity. Food calculated to till
the stomach without enriching the blood, and so leading to
its feeding itself on its stored-up material, as the parenchyma
of vegetables, fish, in all its forms, &c., is desirable. In a
little time the cravings of the appetite become much weaker,
and the self-denial is more bearable, while the feeling of
lightness and activity produced rewards and encourages the
patient. Denial, or, in other words, hunger, is much to be
preferred to an unhmited supply of azotized food, and a
marked increase in the amount of chronic Bright's disease
has unquestionably followed the recent fashionable attempt
to metamorphose man and woman into a carnivorous animal.
The azotized food is partially and imperfectly oxidised, and
the excess of work thrown on the kidneys leads to disease in
them.* Light and subacid wines should not be given with

* The analysis of urine after a non-azotized, a mixed, and a purely azotized

188 THE HEART AND ITS DISEASES.

a highly nitrogenized diet, as they do check kidney action,
and lead to disease in the kidneys, as the post-mortem table
of Vienna abundantly testifies. Gin or whisky, Scotch or
Irish, with potash or Seltzer water, are preferable, or a little
sherry and water. What effect the Fucus vesiculosus, or
common bladder-wrack, really has on the absorption of fat is
yet undemonstrated : it was at one time in vogue as a cure
for obesity. When once the effect of abstinence is marked by
improvement, then moderate and increasing exercise may
advantageously be added. The French advocate the with-
drawal of fluids as a treatment of obesity.

False Hypertrophy, — Any increase in the heart's structure
by anything other than true striped muscular fibre, could be
designated " false hypertrophy." As, however, other diseases
of the structure of the heart walls possess more marked
pathological characters, it is desirable to restrict this term to
an excessive development of connective tissue in the inter-
muscular areolar tissue. This occurs to such a length that the
muscular fibrillas become compressed and Avither, as in fatty
infiltration. From this come symptoms of heart failure, for
there is nothing to lead us to suppose that the excessive con-
nective tissue could give symptoms of its presence. At one
time it was conjectured that hypertrophy of the heart was
not merely due to increase in true striped muscular fibre, but
that fibres of lower grade and imperfect function also
occurred, as fusiform, unstriped, involuntary, muscular fibre,
and even cell elements. We now know that true hypertrophy
is due to hyperplasia of perfect fibres, and that in false hyper-
trophy there is increase of connective tissue merely. This
may attain a great development, as in a heart in St. George's,
weighing 40 oz., the increase being found to be connective
tissue, and not muscular fibre.

Causation. — Various hypotheses of causation have been
hazarded, the favourite one being that it is due to congestion
of the coronary veins, founded on its pathological relation-
ship to the development of connective tissue in the liver,
spleen, and kidneys, in obstructed circulation from heart

diet, shows, by the increase in urino salts, the increase in work the kidneys
necessitated by an azotized diet.

DISEASES OF THE MUSCULAR WALLS. 189

failure. Probably these other conditions are usually found
along Avith it, but there is a difficulty about the affection of
the heart itself. Is it the consequence of obstructed blood
flow ? Or is it the cause ? May not the other similar con-
ditions be due to its action on the heart, and not it a result
of venous congestion. It is not by any means clear ; and
the presence of an advanced condition of development of
connective tissue does not settle anything ; for Sir William
Jenner has pointed out that the heart walls so affected do
not collapse on section, restraining their shape, and recover-
ing it when bent by their own elasticity, like an india-rubber
ball. Now this condition of the heart walls is not by any
means so common as a development of connective tissue in
other viscera, a fact militating seriously against this view of
its origin. Another important fact is that the coronary veins
open through the walls of the right auricle obliquely, like
the ureters into the bladder, and thus not only are the edges
of the openings closed by distension, but the muscular fibres,
such as there are, and they are increased in distension usually,
being stretched, would oppose reflux by closing the vein
betwixt them. The coronary circulation is especially pro-
vided against the effects of distension reaching the heart
itself.

Another view is this, that this is an interstitial inflamma-
tory product, the result of interstitial carditis, and that it is
to be met by the administration of antiphlogistics, and other
anti-inflammatory remedies. The first difficulty in the way
of the treatment would be the difficulty in diagnosing the
condition, until its effects on the muscular fibre were appa-
rent in cardiac debility ; and nextly, the slight action exer-
cised over these interstitial inflammations by any remedies
yet known to us. The first pathological hypothesis is the
more probable of the two, though its acceptance is not nearly
so general.

It is to be feared that too little is yet known about this
affection to warrant any remarks as to its symptoms or prog-
nosis. Consequently it is equally futile to make any remarks
on the treatment of a condition which cannot be recognised
and distinguished in life from the other interstitial affections

190

THE HEART AND ITS DISEASES.

of the heart which increase its bulk. This affection must
still be considered as a post mortem table phenomenon, and
nothing more.

Atrophy. — Atrophy of the heart is a disease which does
not mean merely diminution of bulk, though that is the most
marked form of it, but merely a reduction in the muscular
fibre. As simple atrophy or reduction in size, it is found in
the course of wasting diseases, as phthisis, cancer, &c. It is
then termed simple atrophy. When the term excentric
atrophy is used, the condition of simple dilatation is indicated,
which is a much preferable term in every way. This condi-
tion of enlargement of the ventricular cavities, and stretching
and thinning of the muscular fibre, fi*om its being accom-
panied by no increase in the amount of muscle, has been
described as simple dilatation in a previous chapter, and need
not be again referred to. Rindfleisch describes, as an atrophy
of the heart, muscular wasting with development of con-
nective tissue, and thus no diminution of bulk, well illustrated
by the accompanying plate : —

Fig. IX.

Ealse Hj^pertroplij —

a. Excessive Connective Tissile.
h. Compressed Muscular Fibre.
g. Capillary full of Blood.

He calls this development of connective tissue compensatory
to the wasting of the muscular-primitive bundles. It would
be just as possible, and perhaps more probable to describe it
as an increase in the interstitial connective-tissue, and wasting
of the muscular tissue from compression. Of course this
definition of it and the first one have been fought over
again and again, in reference to the development of this

DISEASES OF THE MUSCULAR WALLS. 191

condition in other viscera. It can only be settled by a
reference to the behaviour of connective-tissue in other parts,
as in the shrivelling of valves, with patches of parenchy-
matous connective tissue in them, the behaviour of it in cica-
trices, &c. It shows a marked tendency to contract and
produce mischief thereby, where no prior atrophy is supposed
even to be present. It is surely, then, odd that it should be
found in excess, along with wasting of normal parts, so singu-
larly associated with this wasting, too, and yet be innocent
causatively. On the other hand wasting may exist without
it, so that the presence of this excessive development of
connective tissue, in atrophy of normal tissues, must be
regarded with some suspicion as the cause of that wasting.

Causes of Atrophy. — These are general marasmus, and a
partaking in a general condition, pressure on the heart by
pericardial effusion, and partially arrested blood supply. It
roay, however, exist congenitally, and very small hearts have
been found in comparatively grown up persons. L. Beale, in
his work on the urinary organs, speaks of a class of persons
mth small hearts congenitally, small bones, and general
plumpness, who seem to give way to kidney disease, and
general breaking up at an early age in a strange manner.

Symptoms. — There are the usual symptoms of cardiac
debility, with increased rapidity. Niemeyer says that simple
atrophy produces a more marked effect on the pulse than
when it is accompanied by dilatation. The heart's impulse is
imperceptible, and its sounds thin and feeble.

Prognosis and Termination. — The termination is untoward,
except in the form due to pericardial effusion and pressure,
and the prognosis is in accordance with its termination and
its pathology.

Treatment is out of question except in the rehef of peri-
cardial effusion, when that is its cause*

Brown Atrophy. — This is an affection found in the hearts
of the aged, and first described by Rokitansky. It consists
of a development of pigment within the primitive bundles,
and extends through the whole heart. Whether it is
derived from the colouring matter of the blood, or muscles,
is not known. It has no symptoms, is unknown clinically.

192

THE HEART AXD ITS DISEASES.

and its interest is purely patliological. A good idea of it
Tvill be formed from the folloA\'ing plate from Eindfleisch, who
states that it is found in marasmatic conditions, not neces-
sarily confined to the aged : —

FiQ. X.

Browu Atrophy (after Eiudfleiscli).

Amyloid Dec/eueration. — This is a somewhat rare affection
of the heart walls, and consists, according to Oppolzer, of the
formation of a shining, colloid-looking material ^^4thm tlie
primitive-bundles. It gives the usual reaction of amyloid
matter to iodine and sulphuric acid, which is not a true bine.
According to Dickenson (on x\lbuminuria), this so-called amy-
loid material is really de-alkalised fibiin from long suppura-
tion. It is usually found in the right ventricle, according
to Rokitansky, especially when the right ventricle is en-
larged.

It has no special symptoms, but is usually found along
with enlarged amyloid liver, spleen of kidneys, with albu-
minuria and tube casts. I regret that it has been impossible
to procure a plate of this disease, as it appears under the
microscope.

Si/2)hilitic Gummata. — These are not imcommonly foimd
in the heart's structure in the subjects of constitutional
S}^3hilis. It has been termed syphilitic myocarditis, but the
action, which results in these gummata, is not within the
muscular-primitive-bundles, but in the interstitial connective
tissue. According to Virchow, the products of these syphi-

litic interstitial inflammations in muscles is a gi'owth of

fine granulation corpuscles, which not uncommonly undergo

J

DISEASES OF THE MUSCULAR WALLS. 193

fatty degeneration into cheesy masses, at one time mistaken
for tubercles, not miliary, but the masses once known as the
yellow tuberculosis of Rokitansky. At other times these
gummata become converted into fibrous masses of connective
tissue.

The masses are scattered through the substance of the
heart just as are gummata in other muscles, and are found from
the size of a bean to a pigeon's-egg (Virchow), or a billiard-
ball (S. Wilks). They are often accompanied by a thickened
condition of the endo- and pericardium, and may be seen
showing through the columnas cornese, under the thickened
endocardium.

The largest are found in the septum ventriculorum (von
Dusch), and project from thence into each ventricular cham-
ber. They have been described by various writers, as Ricord,
&c., and formed the subject of a notable discussion between
Virchow and von Barensprung in the Deutsche Klinik, Avhen
Virchow demonstrated that they were not tubercular masses.

Symptoms, — There are the usual symptoms of cardiac
failure, and as the disease occurs during the prime of life
mostly, it is somewhat unaccountable. The diagnosis is
formed on the absence of rheumatic fever, or valvular disease,
absence of anoemia, or other debilitating cause, or atheroma,
or general decay, &c., the positive evidence of constitutional
symptoms, and possibly of gummata elsewhere.

Treatment. — This is the treatment of syphilis, and Lan-
cereaux found the symptoms relieved by iodide of potassium.
But the treatment must be resorted to early on, as no treat-
ment can be of service, when once caseous degeneration has
gone on, or when the masses are converted into fibrous masses
of connective tissue.

Tubercle, — The true miliary, or gray tuberculosis of
Larnnec, is also found in the heart walls, in the connective
tissue, in cases of acute tuberculosis.

Cancer, — Cancer has been found to attack the heart, as
carcinoma, medullary or melanotic cancer (Virchow). It is
commonly secondary, but may be primary, and Bodenheimer
has described a case of primary nodular cancer of the right
side of the heart.

0

194 THE HEART AND ITS DISEASES.

Parasites. — The heart is hable to be the seat of parasites,
or entozoa, the cysticercus, cellulosa and echinococcus.
They have been known to lead to rupture, and so cause
death.

Polypi, — Polypus of the heart is usually merely a fibrinous
mass, consisting of blood fibrin and white corpuscles, en-
tangled among the chordae tending©, or forming a mould of
the conus arteriosus, and extending up to the artery, with
the marks of the valves clearly to be seen on it.

They are usually found in the pulmonary artery, and are
formed in the death agony.* But real polypi have been
found growing from the inner surface of the heart. GrisoUe
collected authentic cases, and Flint (Diseases of the Heart,
p. 287) describes a case which occurred in Bellevue Hospital,
New York. In this case there were two polypi, both
growing from the right auricle, and one extending into the
right ventricle. The right side of the heart was much
dilated.

The tumours were examined microscopically, and found
to consist of, " 1st, blood-vessels, some of which contained
blood. 2nd. Cells, spindle-shaped, star-shaped, round, and
oval. '018 mm. in diameter, most of them being somewhat
fatty. 3rd. Fibres in broad bands. 4th. Basement mem-
brane, transparent, homogeneous, and finely granular."

There is no diagnosis of them in life given; but false
polypi have been diagnosed in life, once by Dr. R. Drummond,
in York Hospital.

* Various suggestions have been thrown out as to the prevention of the forma-
tion of tliese poljpi, on the supposition that the polypi cause death. Bouilland
thought they might be dissolved by the administration of agents internally.
Richardson has suggested their prevention by giving ammonia. Legroux recom-
mends potash and soda salts. My friend, Dr. Henry Barnes, of Carlisle, has
recently been investigating the subject of fibrinous polypi, and informs me that
in a case where ammonia was given to prevent the formation, which was appre-
hended, of tliis blood-clot, no good resulted, and the clot was found on post-
mortem. From experiments with blood-clot. Dr. Barnes has found that no
result follows from its immersion in a solution of carbonate of ammonia or of
bicarbonate of potash ; little effect from immersion in solution of iodide of
potassium, and ready solution in lime, either in the saccharatcd solution (best)
or lime-water (less effective). It is an interesting subject, but it is not so much
the solution or prevention of the polypi, but the removal of the condition which
favours their formation which we must hope for therapeutically.

RUPTCJRE OF THE HEART. 195

CHAPTER IX.

Rupture of the Heart— Traumatic Injuries —Displace-
ments.

Rupture of the Heart. — This occurs TiSTially in hearts pre-
viously affected by either fatty degeneration, abscess, or
parasite, as hydatid cyst, or is induced by a blow, or fall, or
other injury. It is a not uncommon termination to fatty
degeneration. The seat of the rupture is given by Quain
as most commonly in the left ventricle (76), (and Roki-
tansky points out that it so occurs usually through the apex,
which is most liable to localized degeneration,) then the right
ventricle (13), the right auricle (7), septum (4), and left
auricle last (2). The rupture is sometimes single, and in
other cases several tears are to be detected, some with a clot
of blood in them, as if repair was being attempted, even
under such unfavourable circumstances as the heart's un-
ceasing labour. It would appear from this that a partial tear
may occur, and possibly a rupture is only complete some
time after the tear was commenced. This bears on the
causation, as mentioned before, and often an apparent unpro-
voked rupture really took its origin in some unobserved effort
made some little time before. The tear is often jagged, and
not direct, as if one layer of fibres had given way after
another, near, but not at the same spot, the seat of the rent
in the first layer. These ruptures are usually regarded as
occurring from within outwards, but my friend Dr. Alfred
Wiltshire informed me of a case where the rupture was from
without inwards, and imperfect slits were found on the outer
surface of the heart. This has also been found by others.
The question of whether rupture takes place commonly from
within outwards, or from without inwards, is of interest, as
bearing on the question of its production duiing systole or

0 2

196 THE HEART AND ITS DISEASES.

diastole; and also whether it was produced in systole by-
internal pressui'e, or from the outside fibres tearing them-
selves in an attempt to compel ventricular contraction. When
the rupture is from without inward, it would favour the sup-
position of the rupture being due to the last cause. When
from Avithin outwards, it is possible that it occurred either
from ordinary distension during diastole, or from increased
centrifugal pressure during systole, on a diseased and non-
acting part, which would be in proportion to the centripetal
pressure exercised by the acting sound portions of the ven-
tricle. This last would seem corroborated by its occurrence
in the left ventricle most frequently, next in the right, &c.,
while its occurrence on the right auricle more frequently than
the left would suggest the hypothesis that the rupture
occurred in diastole, the riglit auricle being thinner, and
subjected to the influx from the systemic circulation, and the
left auricle being thicker, and subjected to influx from the
lesser or pulmonic circulation. Before general distension a
weak part would most readily give way wherever situated,
but the probability of the rupture being caused by centripetal
pressure during systole is borne out by the circumstances
under which it occurs.

Immediate Causes, — Though rupture has occmTed during
sleep, there is reason to suppose that the completion of it
only took place then. It occurs during sudden call on the
heart by mental agitation or alarm, by bodily exertion,
dancing, springing, prolonged marches, coition, eflbrt at stool,
epileptic attacks, or arrest of the peripheral circulation in a
cold bath (von Dusch). This would favour the hypothesis
of systolic rupture from mcreased ventricular action and thus
increased general centripetal pressure on the fluid contents
of the ventiicular chamber, and increased centrifugal pres-
sure on the diseased and non-acting parts.

Symptoms. — The symptoms are those of collapse, where
instant death does not occur. The skin is cold ; the pulse
small and irregular, and almost imperceptible; and, indeed,
the same appearances as shock, or fainting, without neces-
sarily loss of consciousness. Tlie diagnosis is rather of
probabilities than certainties, but if there is also increased

RUPTURE OF THE HEART. li)7

lateral dulness, from the pericardium being distended by
blood poured into it, the condition is more surely indicated.
The sudden occurrence of this accident, the sudden shock to
the patient, the intense cardiac suffering, breathlessness, and
feeble, hregular pulse, with loss of heart sounds, and the
collapse continuing, aid to indicate the diagnosis.

Prognosis and Terminations.- — The prognosis is that of
death, certain and unavoidable. It, however, may not occur
for some time, even so far as six or eight days. The rupture
is partially closed by a clot when the fibrous pericardium
becomes so distended as to oppose any further flow of blood
into it at each systole.

Treatment. — This must depend upon circumstances, and
must necessarily be merely palliative, and not curative, in
any sense. It is a complex question how far stimulants do
not increase the flow through the rupture ; but if they give
the patient ease, it is something. Narcotics may be indicated.

Traumatic Rupture. — The heart, in common with other
viscera, is liable to be ruptured by external violence, as falls
from a height, being thrown violently by machinery against
some resisting body, by compression, as by rail-carriage
buffers, &c. The rupture here is through the thinner and
less resistent parts of the heart, as the right ventricle and
the auricles, the left ventricle not being affected nearly so
often. This is the reverse of rupture from disease. Death
inevitably is the result, unless the septum be ruptured, and
then cyanosis results.

Wounds of the Heart. — The heart is liable to be wounded
by penetrating wounds of the chest, whether bullet wounds,
sabre, bayonet, or knife wounds, either self-inflicted, homi-
cidal, or in war ; it has also been unintentionally wounded
in excision of the mamma and other tumours over the left
breast, and has been pierced with a trocar, when a dilated
heart was mistaken for a collection of fluid in the pericar-
dium. It has been wounded by needles and pins, &c., fixed
in the oesophagus ; in that case the posterior surface of the
left ventricle was injured. From wounds inflicted in front,
the right ventricle, from its position, is most commonly
wounded, but the right auricle and left apex are also exposed.

198 THE HEART AND ITS DISEASES.

The heart has been partially cleft, a sword cut in the sep-
tum ventriculorum, with what result cannot be remembered.
Many strange facts are recorded in connection with injuries
to the heart, but these belong rather to collectors of terato-
logical data than to a sober treatise. Bullets have been
found encapsuled in the substance of the heart, and without
any external scar, giving grounds for the hypothesis that
they must have penetrated one of the great trunks, and
fallen into the ventricle.

Wounds of the heart are usually fatal, but it would not
appear necessarily so, unless they are penetrating, or cut a
coronary aj'tery, or one of the larger branches. Pericarditis
is, no doubt, a result of injuries through it ; but the whole
subject is too mifrequent to give as data as to what occurs
after wounds of the heart — not being immediately fatal.

Treatment, — Where the wound is slight and not through
the heart walls, the patient must be kept quiet in bed, and
if the heart's action is tumultuous, aconite might be given.
Local treatment is out of question.

Displacements of the Heart. — The heart may be displaced
by a fall, or other violence, by disease, or may be congenitally
out of its ordinary place. The subject is of interest as
bearing on the diagnosis. So accustomed are we to think of
the heart being on the left side, and associated with the left
nipple, that when not so situated some doubt might exist as
to the diagnosis. We are now pretty familiar with the fact
that the heart is commonly displaced to the right by effusion
into the left pleura, and from the formation of pleuritic ad-
hesions, &c., it may remain there. It is also liable to be
displaced by an emphysematous lung, or drawn over by
retraction and shrinking of the right lung, by cancer, and by
diaplnagmatic hernia (Da Costa). A case is related by
Cheyne, of Dublin^ in the Cyclopaedia of Practical Medicine,
of disjjlacement of the heart to the right side, occasioned by
an accident, where it remained, palpitating a good deal till it
got accustomed to its new quarters. Here simple rupture of
the pericardium must have allowed the heart to escape,
while it did not admit of its being drawn back by the elasti-
city of the vessels.

RUPTURE OF THE HEART. 199

Stokes had once a case of disease in a person in whom
the heart was congenitally on the right side, and diagnosed
it correctly.* The positive presence of the signs of disease
of the heart in the right half of the thorax does not invali-
date the diagnosis, only, of course, such cases are rare. The
Pathological Museum of Vienna, however, now possesses
two specimens of reversal of the position of the viscera, the
heart and spleen being to the right side and the liver to the
left. My friend Dr. Elliott, of CarHsle, has had long under
care a patient in whom he has diagnosed this condition, and
his opmion is corroborated by Sir Robert Christison and
others.

•

* " Diseases of the Heart," p. 463.

200 THE HEART AND ITS DISEASES.

CHAPTER X.
General Teeatiment of Heart Disease.

The treatment of diseases of the heart is a subject on which
unfortunately too much doubt and too httle hopefulness
exist. While it is perfectly true that a diseased valve can
never be restored, and that the molecular necrosis, fatty de-
generation, is not a very good subject on which to demon-
strate the efficacy of remedies, it must not be taken for
granted that all disorders and diseased conditions of the heart
are equally removed from the reach of therapeutics. In a
great number of cases of mere failure of the muscular struc-
ture of the heart and dilatation, not complicated by valvular
disease, restorative treatment is followed by most satisfactory
results. Such cas(is may occur after debihtating illnesses,
terminating in protracted convalescence ; after long and
arduous exertion, as in nursing the sick, where one person is
too unequal to the necessities, and where the slight rest per-
mitted is too often taken in the sitting, and not the recumbent,
posture ; long over-exertion in agricultural service, or in
large works, excessive gymnastic exercise, &c. Here the
removal of all call for exertion, perfect rest, especially in bed
for a time, and proper remedies, will give great relief in every
case, and in a large number perfect restoration to health is per-
missible. Even when a valve is injured, great compensatory
growth of the muscular walls Avill permit not only of fair
health being maintained, but even of great exertion bemg
Tuidertaken, without any bad results.

Niemeyer relates a case of a huntsman of the Griefswald
who, though suffering from aortic regurgitation, went through
forced marches, and other severe calls on the powers, in the
war of 1866 quite successfully. Growth in the left ventricle
compensates more or less perfectly for disease at the aortic
orifice ; in stenosis tlie increased power enables an equal
amount of blood to be driven through a smaller opening in

TREATMENT. 201

an equal space of time, and thus, for long, of perfect com-
pensation being maintained ; and the above case of Niemeyer's
shows how the hypertrophy, so invariably found to a marked
extent m aortic regurgitation, had resisted the backward
flow through the incompetent valves on the aortic recoil.

Mitral disease is met by increased growth and power in
the right ventricle, which is not lost in the short pulmonic
circulation, and stenosis and regurgitation are thus met, as
by the left ventricle in aortic disease. Thus mitral disease
will continue for years compatibly with a fair amount of bodily
vigour, and without much inconvenience to the sufferer. I
have seen growth, and rapid growth too, with the perfect
establishment of puberty, well maintained in a girl with a
very considerable mitral regurgitation, and whose condition
at the commencement of treatment was far from encouraging.
While we know only too painfully well that a distorted or
contracted valve is beyond tlae reach of our art, and that
though connective tissue is soluble in a solution of barytes,
we are yet as far as ever from seeing how to remove the
growth of it, which has injured the valve, even if it were
possible to hope that after its removal the valve would
assume its former and normal shape. Still this muscular
compensation, so successfully established by the self-curative
power of the system itself in many cases, is to some extent
under our control. In all systems of good reparative power
all call upon the muscular walls leading to distension of the
ventricular cavity, as we saw in Chapter YII, tends to pro-
duce hypertrophy.

This, there is reason to believe, is thus brought about.
Distension which involves the elasticity of the muscular
fibre itself, that is, extending beyond normal distension
till the full length of the fibres is reached, and involving
the secondary elongation of the fibres, or their elasticity,
creates an impression on the cardiac ganglia. This is
quite in accordance with what we know ; it is merely the
normal stimulus in excess. . From recent experiments we
learn that the heart possesses a sensory nerve, a fact which
we could conjecture from the pain accompanying heart
affections, and especially acute ones, and this nerve has

202 THE HEART AND ITS DISEASES.

been found to be a vaso-inliibitory nerve, i.e., it arrests
vaso-motor nerve action and dilates the peripheral muscular
extremity of the circulation, the arterioles. Thus is not only
tension of the arterial system lessened, and with it the oppo-
sition offered to the heart's more completely emptying itself
at .each systole, but this aifects the arterioles of the coronary
circulation, and thus " a broader and more rapid stream of
blood" is furnished to the heart itself; and so leads to
hypertrophy. This is the causation of hypertrophy as it
appears in the present state of science. It is borne out not
only by the causes of hypertrophy, mentioned in a previous
chapter, but also with Traube's famous definition of hyper-
trophy, without visible dilatation, or complete compensation ;
hypertrophy with dilatation, or incomplete compensation ;
and simple dilatation, or no compensation. Distension
leads to dilatation in systems unequal to compensation, and
is arrested by hypertrophy ere dilatation is established in
systems with better vital force ; while all grades of inter-
mediate, incomplete, compensation are found. This is
nature's treatment, but it is not always successful. Much,
however, can be done by therapeutics. The blood itself may
be enriched, and the dilatation may be due to anoemia or
spanoemia, by haematics, iron, &c. While agents which
increase ventricular contraction not only arrest the dilating
process, and tend to institute a return to the normal size,
but also affect the circulation most advantageously. For we
know that dilatation takes its origin in incomplete systole,
and a certain amount of blood remaining in the ventricular
chamber, when the blood rushes in from the veins ; for the
blood will pour into the ventricle as long as the pressure on
the ventricular wall is less than on the venous walls, i.e.,
until the pressure in veins and ventricles are equal, and no
further. But when the ventricle is imperfectly emptied, a
compromise takes place, in distension of the ventricle and en-
gorgement of the veins, in exact proportion to the amount
of blood already on the ventricular chambers. This is self-
evident enough ; it is a mere question of pliysics.

Thus, with dilatation we get venous engorgement, one
source of distress and mischief, and imperfect filling of the

TREATMENT. 203

arteries, another source of trouble. For the elastic arteries
transmit what is poured into them. If, then, a small bulk of
blood only is thrown into them at each ventricular systole,
the supply of arterial blood to all parts is diminished, includ-
ing the heart itself. Thus dilatation has a tendency to per-
petuate itself, by this imperfect blood supply, in spite of the
beautiful nerve arrangement for increased nutrition in dis-
tension.

But when an agent increasing ventricular contraction is
administered, more perfect ventricular contraction passes, at
each systole, a larger bulk of blood into the arteries, this
leads to better supply of arterial blood generally, and relief
of all parts. But this includes the heart itself, thus : 1. More
perfect ventricular contraction causes a larger bulk of blood
to be thrown into the arteries at each systole. 2. This pro-
duces more perfect arterial distension. 3. This, in the elastic
arteries, leads to more perfect recoil. 4. The aortic systole
is the propelling power into the coronary circulation, and
more perfect recoil leads to improved coronary circulation ;
and 5. This conduces to more perfect nutrition of the heart
itself

But, at the same time, another important matter has been
brought about. We saw in Chapter I that increased rapidity
in the ventricular contractions took so much off the heart's
sleep, i.e.^i so many more contractions in each minute took off
the time, taken up by these abnormal contractions, from the
diastole, or period of rest. This distension of the heart
chambers induces rapid imperfect contractions ; and more
perfect contractions allow of a longer diastole. The effect
of slowing the pulse is universally allowed to digitalis, when
that pulse is abnormally fast.

Thus we have secured a longer diastole and so many
fewer systoles each minute, or longer sleep, at the same time
that we have improved the blood supply to the heart itself.
This is all sober fact, but its effect in aiding a heart, not
quite equal to hypertrophy by its own efforts, is often wonder-
ful. These positive curative measures of rest, diminished
call on the heart for exertion, improved condition of blood
by haematics, and direct action on the heart by agents which

204 THE HEART AND ITS DISEASES.

induce ventricular contraction, will often establish a hyper-
trophy, if the dilatation is irremediable ; at other times
restoration of the heart to the normal ; and even when a valve
is positively injured, a great approach to this can be attained.
In a great, a very great number of heart cases, hopeless-
ness is unfair to the patient and unworthy of our present
knowledge. If in some cases where molecular necrosis is
slowly cutting down the muscular structure, we must look on
with a feeling of incapacity to be of much service ; it is not
so in a large majority of cases. Both in justice to the patient
and ourselves, hope can be held out, and despair need not be
indulged in. " We see too much of the recovery of heart
power by rest, food, and proper medicines ; we know too
many pulses that are beating happily now that we knew to
intermit or be irregular years ago " {Lai2cet, leader, April 27th,
1872), writes a well-known medical authority, in speaking of
the treatment of diseases of the heart, as it can be conducted
now, to permit despair. The fact that a great proportion
of cases of disease of the heart comes now under the heading
of curable affections, and that another large proportion can
be relieved, when not admitting of cure, is as certainly ascer-
tained as that other forms are incurable and admit only of
palliative treatment, and that, too, to a limited extent.
Which form he has got before him, must usually be determined
by the diagnostic skill of the practitioner, and on that diag-
nosis lies very often the practitioner's hopefulness, and with
it the patient's chances of existence. For if time be lost, the
case may proceed to a point admitting to a much smaller
extent of treatment than when medical advice was first
sought. There is a grave moral importance, involving one's
duty towards one's neighbour, a very elementary moral law,
about the formation of a diagnosis very often in medicine ;
for on that diagnosis often hangs the prognosis and the
treatment. And treatment may often much affect the prog-
nosis, and no treatment, or improper treatment, may verify a
prognosis in a very unpleasant manner. Even when in doubt,
it is better to err on the side of treatment, which is not
harmful even where it is not successful, and may often achieve
results not hoped for, than to allow valuable time to slip

TREATMENT. 205

away, and a fellow-creature's life to dwindle out for lack of
aid ere it is too late.

It is but a base return for a patient's confidence to meet
it by an ignorance wbich is removable, or a hopeless scepti-
cism which is not justified by facts. Had I not too often
seen what is now being described, perhaps the expressions
might be somewhat moderated, but tliey are within and not
over the mark.

One of the most unfortunate scepticisms in relation to
diseases of the heart arises from the often wonderful effects
of rest. This is mostly seen in hospitals. A patient with
dyspnoea, cyanosis, feeble irregular pulse, and. small bulk of
urine passed in the twenty-four hours, is taken in and put
into bed by the house surgeon, or clinical clerks, in the pre-
sence of a class of students. No treatment is decided upon
until the case is seen by a physician, and in the mean time
the patient improves very much, his cough is less trouble-
some, his respiration less impeded, he can breathe lying
down, or with much less propping, and the pulse becomes
much steadier. This improvement is so striking, that " the
expectant treatment " is continued until the patient is suffi-
ciently recovered to resume his occupation. The case creates
comment, and illustrates beautifully the effect of rest as part
of the treatment of heart disease, leaving the impression on
many minds that rest in bed is the treatment, par excellence,
for heart failure. But follow that patient a little longer,
and see the effect of the resumption of exertion, the
toil necessary to procure the daily bread, and you would
see every symptom return with its former or increased
force. The heart is quite equal to the call upon it when
lying in bed, and even to somewhat of compensatory
growth under these favourable circumstances, but the re-
sumption of toil soon brings out its incapacity. Rest in bed,
valuable as it is, is only part of the treatment of heart
failure, and will do little for those who must work or hunger,
except as an occasional indulgence ; and as such it is most
valuable to many of our toiling populations^ especially in
towns where they can be received for a few weeks into a
hospital ward.

206 THE HEART AND ITS DISEASES.

For the more perfect general comprehension of the sub-
ject of the treatment of heart disease generally, i.e., the
elements of treatment, to be applied to each individual case
according to its necessities, by the good sense and at the
discretion of the medical attendant, the treatment will be
divided into three sections : 1. The removal of causation, as
far as is practicable ; 2. The means of acting upon the heart
itself; and 3; The rational treatment of sequelas, i.e., the
palhative treatment of the consequences (riickwirkung) of
heart failure.

Removal of Causation. — In the treatment of all affections,
this constitutes the first step ; but it is unfortunately too
often beyond our reach. In the heart, however, which acts to a
large extent mechanically, this is possible to a great extent.

All call for exertion soon tells on a heart which no longer
possesses any spare power, but is actually unequal to its
labour, to the demands on it. This effect of exertion upon
the heart has all along been used as the test of structural
inability, as the means of diagnosis betwixt the objective
symptoms which are alike the result of disordered innerva-
tion or of structural weakness. It becomes of great import-
ance then that when cardiac symptoms show themselves in
the hammerman or striker, the collier, or other person, whose
occupation necessitates violent efforts, to insist upon some
other form of occupation making less demand upon the heart.
This is often a difficulty to a working man, but the alternative
must be put before him. For it is only too obvious that the
form of labour which evokes the failure must be abandoned ^
for the causes which could induce disease in the healthy
heart must have a sadly deleterious action when that organ
is commencing to yield, and the various forms of compensa-
tion to become imperfect. No measures, however successful
in affording relief to symptoms, can be expected to endow
the organ with the virtue to resist the stress with impmiity.
If, then, the i-ioour is persisted in, an unfortunate result can
alone be anticipated.

The same may be said about exciting mental pursuits, and
more especially in monetary speculators, and others whose
occupations are exciting; for Quain, Richardson, and others

TREATMENT. 207

tliink, not unwisely, that the increased rate at which we live
" in this madly striving age," exercises a decided influence
in the production of heart disease, and that its increase in
the death returns is not solely due to a better recognition
of it, but to S(jnie extent to an actual increase in frequency.

All conditions which tend to weaken the patient, from
bodily causes, must be removed, or relieved as far as it is
possible. Thus indigestion, mal-assimilation of food, as pre- "
venting the proper nutrition of the blood, all debilitating
discharges as chronic diarrhoea (this is in early stages ; in
latter stages it is somewhat different), dysentery, haemorr-
hoids, bronchorhoea, &c., must be amended by treatment as
far as they permit.

Imperfect blood-nutrition, however produced, leads to
loss of propulsive power in the heart. Anoemia is ever to be
averted in cases of heart failure. Flint (Diseases of the
Heart, 1870) says, " The combination of anoemia and enlarge-
ment of the heart is to be prevented, if possible, and, if it
exist, anoemia, if possible, is to be removed by appropriate
measures of medication, diet, and regimen. Irrespective of
this condition of the blood, all agencies which tend to weaken
unduly the force of the ventricular contractions, are contra-
indicated. In proportion to the weakness of the heart will be
the tendency to dilatation rather than to hypertrophy. So
long as hypertrophy predominates, the patient is compara-
tively safe" (p. 77). What gives this decided expression
even more force is that here he is speaking of the treatment
of hypertrophy.

When dilatation is manifesting itself, it becomes doubly
important to avoid any tendency to anoemia ; and where this
tendency does not yield to treatment, but manifests an in
clination to persist, the patient should be remorselessly con-
fined to bed for a time, to reduce to a minimum the calls on
the nutritive processes. This is often necessary after debili-
tating diseases, or where the heart itself has been affected, as
in some febrile or inflammatory conditions, when the
weakened muscular fibre is unequal to complete ventricular
contraction upon its contents, and where both ventricular and
venous distension are resulting.

208 THE HEART AND ITS DISEASES.

Pretty much the same effect upon the heart as is produced
by anoemia, is produced by nervous exhaustion of the gan-
glionic or organic system chiefly. This is what is meant by
vital exhaustion. It is not mere mental tire, it is not cere-
bro-spinal exhaustion, but sympathetic. The effect of this
exhaustion is to impair the sensitiveness of the cardiac gang-
lia, upon which depends carclia contraction.

When, then, from any impairment of this sensibility a
condition of over-extension results, there follows imperfect
contraction, and thus dilatation is inaugurated. All causes
then w^hich lead to loss of power in the pulse, and especially
when this is accompanied by increased rapidity, indicating
ventricular over-distension, should be avoided. These are
excitement of all kinds, including excessive drinking on the
one hand, and attendance on special lectures, meetings, or
services on the other, the denial of sleep, especially in the
horizontal posture, tobacco smoking to excess, similar use of
tea, &(;. Frequently it will be found that a case has such an
exciting cause, so removed from common experience, as 'not
to be found in any text-book, but which will at once point to
its action and the necessity from its non-continuance.

The effects of all causes, or agents, which lead to nervous,
vital, exhaustion, and increased frequency, with loss of power
of heart contraction, is strictly analogous in effect, to imper-
fect nutrition or anoemia. The complete or partial removal,
where complete removal is not feasible, of these causes is
imperatively demanded in the treatment of the heart Mlure
which results from them.

Where certain blood poisons, as in Bi'ight's disease (see
Chapter XTII), malaria, syphilis, lead-poisoning, &c., are the
cause of impaired blood formation and nutrition, their
removal by their various treatment, by specifics, so called, or
otherwise, is clearly indicated.

A great number of cases of heart disease presenting them-
selves to the practitioner, whether simple muscular failure or
accompanied by valvular disease, will be found witli a fair
amount of capacity for exertion, or in other words, in the
early stage of the case. Here it is commonly only necessary
to economise the forces, by diminislicd exertion, to avoid ex-

TREATMENT. 209

hausting causes, of all and every kind, and to resort to some
of the combinations of remedies, mentioned in the next sec-
tion, to cure absolutely in some cases, and in others to relieve
for long your patient. With how much judgment and skill
this is done will seriously affect your patient's chance of pro-
longed existence. It must also be borne in mind that relief,
amounting to cure practically, will often be followed by for-
getfulness of the physician's warnings, or a feeling that he
might be too serious in his admonitions, or take too grave a
view of the case, and it is ever easy to believe what we wish
to believe, and the improvement in bodily vigour is followed
by further calls upon it, the old groove is easy again to slip
into, and a repetition of the causes will restore the condition
of the heart, and again necessitate consultation of the
physician ; each time with a worse prognosis it will be found.

This was well seen in an old Irishwoman, a whilome
patient, who was so quickly relieved by treatment, that she
became quite indifferent to her dropsy and dyspnoea, getting
rid of them almost so soon as she wished to. Relief was im-
mediately followed by the resumption of a black pipe and
the " cratur." The whole thing became very absurd, but in
a few months it became serious, and too long delay in resort-
ing to treatment was followed by rapid aggravation of all
the symptoms, and death.

But unquestionably the tendency of most cases is to be-
come steadily worse, often slowly and very gradually. Thus
the patient relieved by treatment for a time, and the effect
upon the heart of digitalis and iron persists for some time
after their withdrawal, comes under treatment again, with
either some consequential ailment or his symptoms brought
back by some affection caught casually, but partly the con-
sequence of his lessened power of resistance. This period
of ill-health, or disorder, has brought out the heart's
inability.

Treatment will probably restore him, if the disease has
not been too serious, for some time, but it is only for a time.

The increasing dyspnoea or some visceral complication, the
result of abdominal plethora, is now the complaint. Each
time a more involved affection will call for a more elaborate

P

210 THE HEART AND ITS DISEASES.

treatment, and simple action on the heart itself must be
aided by some agent belonging to the last section, or the
treatment of sequelae. Again, a fair amount of health may
be fortunately attained, but the case is gradually coming to
a close, if not abruptly cut off by some sudden failure or pul-
monary congestion. And of course the liability to sudden
death increases as a condition of greater heart debility is
reached, but it must be borne in mind the majority, and large
majority too, do not die suddenly ; indeed it is in one sense
a pity that they don't die suddenly, somewhat oftener. The
distinct tendency is to grow slowly worse till the defect in
the circulation is affecting every organ, and felt in every
function. In time the patient becomes almost a constant
invalid, his permanent treatment of digitalis, iron, and usually
some acid, or with a vegetable tonic containing tannin for
the catarrhal stomach, supposited for the iron, only varied by
some cough mixture, or by cathartics, and the use of the
bath, or the application of some external treatment. The
general principles of this treatment are arranged, systemati-
cally, and the reader is thus reminded of certain remedial
measures which his own intelligence will apply to the needs
of each individual case, a combination often being indicated.
Means of Acting on the Heart itself. — The means by which
we may act upon the heart itself are necessarily of three
kinds — those acting on it from without, i.e.^ affecting it
regionally ; those acting on it from within, the reduction of
the bulk of blood circulating in it ; and those which act upon
its muscular walls directly. The action on the heart by
pressure around it is only too obvious. This is most espe-
cially seen in the accumulation of fluid in the pericardium.
But equally and much more commonly visible is the effect of
pressure upon the abdominal surface of the diaphragm, and
its bulging into the thorax, thus diminishing the space
within wliicli the heart moves in its action. The heart
varies in bulk in systole and diastole, betwixt full distension
and the chambers when emptied, it is obvious, then, that
while the bony parietes of the thorax remain in statu quo,
and the diaphragm is pushed upwards in the neighbourhood
of the heart, the heart itself must be affected by that pressure.

TREATMENT. 211

That it is so is a fact well known in clinical experience, even
in healthy hearts, as in accumulations of gas, solids, &c., in
the stomach and colon : how much more they affect a heart
already impaired is equally well known. The sense of dis-
comfort, shortness of breath, and palpitation, which are found
very unpleasant in a sound person, is intensified in a person
with a diseased heart; and this more especially when the
right ventricle is involved. The accumulation within the
colon or stomach of gas must be met by carminatives, stimu-
lants, diffusible or other; and in favour of ammonia has been
urged a chemical argument. It has been asserted that a re-
duction of the bulk of gas takes place by its union with the
free ammonia, converting it into a carbonate ; whether this
is so or not, it is certainly a useful stimulant in this condition.
When the accumulation is solid, purgatives, and in acute
dyspepsia emetics are useful, ipecacuanha or sulphate of zinc,
or both combined. Turpentine stupes are, too, desirable. In
connection with this subject is involved that of the relief
afibrded by retaining the sitting posture, or being propped
up in bed, in heart disease, and especially in the acute
paroxysms of dyspnoea. There is no question as to the fact.
The explanation is not so simply answered; but, after de-
liberate thought, it appears most probable that the relief is
not in the respiratory passages being so brought or kept in
a straight line, as has been asserted, as when the patient
seeks relief by sitting on one chair, and resting his arms on
the back of another (here the fixing of the arms enables the
auxiliary muscles of respiration to act more efficiently), or
desires to be propped up in bed, or dies sitting in a chair.
At other times, when seized with an acute paroxysm, the re-
clining patient jumps up in bed, gets on his or her hands and
knees, retaining this posture for hours, uncomfortable though
it is at other times. It lies in the regional relations of the
diaphragm. When in the reclining posture, the contents of
the abdomen do not fall from the diaphragm by their own
gravity, but press equally on the diaphragm as on the other
parietes ; and this, too, markedly when any load or pressure
exists in the stomach or colon. This is at once relieved by
elevating the upper portion of the body, or in the attitude on

P 2

212 THE HEART AND ITS DISEASES.

hands and knees. Whether this is all the explanation or not,
there can be no question that it is part of it. All pressure
from without upon the heart impedes its action, and on its
removal the heart is relieved.

The question of action upon the heart from within, by re-
duction of the bulk of blood in the venous centres, and
especially during distension of the right ventricle, has been
discussed and even debated only some few years ago. Most
members of the profession will remember the memorable dis-
cussion on bleeding betwixt Dr. Markham and Sir Thomas
Watson on " The Change of Type in Disease," and will also
be more or less familiar with the more recent elaborate paper
" On Bloodletting " by B. W. Richardson, F.R,S, The ques-
tion briefly is the relief of over-distension of the right heart
by the withdrawal of blood from the circulation. In cardiac
asthma the right ventricle is in over-distension, and at the
point of paralysis therefrom, in its inability to drive the blood
through the capillaries of the lungs. This condition is un-
fortunately very frequent in the course of chronic heart
disease, and may arise from diaphragmatic pressure, when in
the horizontal position, or from spasm of the pulmonary
arterioles, &c. Here, again, the question of the relief afforded
by the withdrawal of blood generally or locally is not one
about the fact : that is unquestionable enough ; but whether
the immediate danger would justify resort to the measure in
the face of the danger looming of oncoming anaemia. A few
ounces of blood are not much to a healthy person, but amount
to a great deal in a person with advanced heart disease.
Consequently, the tendency of practice is to draw blood away
from the venous centres by means which do not necessitate
its removal from the system. Thus, one method much
resorted to is the diminution of the bulk of blood by the
administration of purgatives. Another aad more speedy
plan is the dilating of the innumerable capillaries of the skin
by the application of heat, of irritating materials, or both
combined. The application of mustard poultices and blisters
are measures of no recent adoption ; but the advance of
knowledge has demonstrated that the efiect desired can bo
more quickly and surely attained by the application of hot

TREATMENT. 213

poultices around the trunk, or as far as is practicable. They
at once dilate the capillaries of the skin, and thus furnish
relief to the gorged venous centres : thus acting in a manner
precisely similar to the withdrawal of blood by bleeding.
Mustard may or may not be added to aid their efficiency by
its irritant action, or by its action as a general stimulant.
The use, then, of this method of unloading the venous cen-
tres is in practice preferable to that of withdrawing blood
from the organism for ever, as is unquestionably the case
with general or local depletory measures, and is thus to be
resorted to first ; but the question of resorting to further
measures when these, combined with the administration of
internal remedies, fail, is whether the emergency is sufficiently
great or not. Several times has the writer stood, lancet in
hand, some time, carefully watching the action of the other
measures, and, on their success, returned the lancet unused.
Though the relief of this condition by venesection must be
seen to be appreciated, still the immediate advantages must
be weighed against the loss of that blood permanently. No
doubt, in practice, local bleeding by leeches is largely resorted
to, and so, but for the natural objection to the cutting of the
skin, would be wet-cupping ; dry-cupping is not so useful
here as the covering a larger surface with hot poultices, how-
ever useful it may be when applied to a localised surface to
divert to the skin the blood of an artery whose internal dis-
tribution supplies an internal organ affected, as over the loins
in kidney congestion, or in costal pleurisy, &g.

In addition to these measures of acting on the heart from
outside and within it, is the question of acting on the heart
itself by means of remedies. Can we increase and diminish
the completeness and power of the ventricular contractions,
is a question which can now be answered in the affirmative.
There do exist agents which positively stimulate the heart
walls into increased contraction. Thus the condition of the
heart walls, as regards distension, is brought within the reach
of remedial agents administered internally. The effect of such
an agent in the condition described immediately above, is to
cause the ventricle to contract more perfectly ; and thus it is
not only relieved from the danger of paralysis from over-

214 THE HEART AND ITS DISEASES.

distension, but aided to recover itself. No sedative to the
heart is needed here betwixt its distension and the risk of
paralysis from the carbonic acid of the highly venous blood
within it ; it is only already too powerless, but some agent
which will enable it to contract more efficiently. That we
are in possession of such agents is certain. The chief one in
use is digitalis. The names of Sanders, Orfila, Traube,
Dybkowsky and Pellikan, Handheld Jones, Hilton Fagge
and Stevenson, Reich, Niemeyer, Winogradoff, are intimately
associated with this subject ; and though the earliest impres-
sion of its action was that it was a sedative, because under
it the heart grew quieter, still, from the work of Withering,*
in 1785, down to the most recent investigation by the writer,t
the idea has gained ground that this quieting of the heart's
action arose from its being endowed with more power. Allied
to it are other agents, as the scilla maritima, associated with
the names of Fagge and Stevenson ; the dajasck, or arrov/-
poison of Borneo (Braidwood), unquestionably belladonna,
associated with the names Meuriot, and notably Dr. John
Harley; the alkaloid of veratrum, advocated by Trousseau,
Aran, Yocher, and Horatio Wood ; caffeine, the writer ; others
of the scrophulariacese,! and probably scoparium ; and pos-
sibly some of the trial poisons of the tropics. Physiological
experiment demonstrates what clinical observation had long
expected, that the effect of digitalis is to produce more per-
fect action of the ventricles. The condition of complete
paralysis by aconite, identical with that of the over-distended
heart, was quickly relieved by the administration of digitalis,
and not only so, but that previously paralysed heart, in ex-
treme distension, can be brought to a stand-still in the
opposite condition of complete contraction, if enough of digi-
talis be administered. In practice, then, digitalis can be
administered with excellent effect in tlie condition of over-
distension of the ventricle, and has been so used. In all con-

* " On Foxglove." Birmingham, 1785. Leipzig, 1786.

t *' The Hastings Prize Essay, 1870." " Digitalis : its Mode of Action, and
its Use." H. K. Lewis, 1871.

X Some experiments by Dr. II. Barnes, of Carlisle, and Dr. J. Wallace, of
Dalston, now of Liverpool, on other members of the scrophulariaceoe, may some
day see light.

TREATMENT. 219

improvement in the circulation is followed by freer circula-
tion through the kidneys and better arterial tension, and^
consequently, there is better diuresis of water.

Diuretics have not only always been resorted to in the
treatment of dropsy, which was, until recently, regarded as
a disease 'per se and not a sequel, but the improved or
altered flow of urine has been adopted as a sort of test of
the efficacy of the remedial measures resorted to. Long
before the experiments of Pnaff, Winogradoff, Traube, Hand-
field Jones, and Brunton, on arterial tension, popular obser-
vation had learnt that an increased flow of urine indicated
an improvement in the patient's immediate condition in
dropsy; and it is, therefore, in the agents classed as diure-
tics that we find digitalis, squill, belladonna, &c., which we
now know exercise their diuretic action by virtue of the
increased arterial tension, the result of more perfect ventri-
cular contraction. The water excretion by the kidneys is a
question of hydraulics — a purely mechanical result of the
pressure of the blood on the thin-walled glomeruli of the
Malpighian bodies. When the arterial blood is driven in but
feebly, and the venous is almost stagnant, we find the bulk
of urine very low indeed : but its sp. gr. may be very high,
for the bulk of urine and the elimination of solid excreta by
the renal secreting cells bear no necessary relation to each
other. No doubt, too, certain other agents act as diuretics,
as juniper, turpentine, potash, nitrate, nitric aether, &c., by
their being direct stimulants to the kidneys, and thus in-
ducing an increased flow of blood to these organs. But it
is in the first division we find our agents which are the best
diuretics in heart failure, and what position scoparium should
hold it is difficult to say from want of observation experi-
ments, but it will probably be found among the first named.
The other class of diuretics, as colchicum, cantharadine, and
buchu, &c., which increase the amount of solids without
afiecting the bulk of urine, are not to be regarded as diure-
tics in the treatment of heart failure.* Stimulants are

* The Americans seem better acquainted than we are with the difference
betwixt water diuretics and solid diuretics ; and this is due to the adoption of

220 THE HEART AND ITS DISEASES.

diuretics insomuch as they increase the completeness of the
ventricular contractions and improve arterial tension.

Diaphoretics are not yet sufficiently adopted as a means
of affording relief in dropsy and the sequelae of heart failure ;
but it is not only a very effectual, but, in my experience so
far, a perfectly safe way of increasing water elimination,
especially when the heart failure is accompanied by renal
disease. The sitz-bath is a good form, or any bath which
permits the patient to breathe freely : Turkish baths are
regarded as not very safe.* Another plan, devised by the
late Sir James Simpson, has been so useful that it cannot be
omitted, and that is, to fill six or eight lemonade bottles
Avith boiling water, cork them well, and draw over each a
woollen stocking Avrung out of hot water, then pack them
round the patient in bed, who in fifteen minutes or so com-
mences to sweat profusely : they can be continued for an
liour, or repeated when necessary. This plan can be resorted
to with the poorest patients, and when a patient of any class
is confined to bed. In obstinate cases where the skin will
not be induced to relax by hot baths, cold packing has been
resorted to in order to paralyse the minute vessels of the
skin, and thus produce dilatation of them in cases of chronic
kidney disease ; but I am not acquainted with the details as
to whether cases with distinct heart failure were so treated
or not.

Dropsy is not only a great cause of suffering to a patient
with heart disease, but is regarded by non-professional
people as indicating great danger to existence. It is, no
doubt, a sign of failing power of serious import ; still its
occurrence often gives temporary relief. When the distended
venous system is relieved by a sudden general oedema, great

the conclusions of Hammond in his essay " On the Action of Certain Vegetable
Diuretics," 1859.

* On the other hand, Dr. Briatowe, in Croonian Lectures, 1872 {Brit. Med.
Journ., May 11th), says, "I treated my anasarcous patients largely by the
Turkish bath ; and I was soon surprised to find how well those who were
seriously ill bore it, and how much they were, for the most part, benefitted by it.
Indeed, I began by degrees to employ it in the treatment of such cases almost
indiscriminately, and both for cases of heart disease and renal disease, whether
a':;uto or chronic."

TREATMENT. 221

and immediate relief is experienced, and that may be utilised
to improve matters and to induce re-absorption. But usually
dropsy commences insidiously, retreats for a longer or
shorter time under proper treatment, but usually it is not
long in returning, and is more persistent in each reappear-
ance. If, during the interval, the patient has been under
good treatment, and yet, in spite of it, it returns, it is a prog-
nostic sign of the very worst import : no worse sign can
exist, and its reappearance calls for the most energetic treat-
ment. Sometimes oedema is very capricious in its seat, and
flits about in a curious to-and-fro manner; in one well-
remembered case, where the lesion was tricuspid, the oscilla-
tions from legs to lungs and back again were very marked
If the patient was found with a less agonized countenance,
his legs were tremendously swollen, when he was gasping
for breath his legs were fallen. Dropsy, as a sequel to heart
disease, is amenable, more or less, to the measures cited
above, in addition to which is the question of puncture.
Nature oftentimes establishes a drain of her own ; not always
with good effect. Puncture, or incision, is, in my personal
experience, in most cases worse than useless, and only adds
a wet bed to the patient's sufferings. One case only can I
recall where the benefit was decided and unequivocal. Others
have had a less unpleasant experience, but it is in dropsy
from heart and kidney disease combined that the benefit of
puncture or incision is chiefly seen. In simple heart failure
it is a hazardous proceeding, and sometimes the carbonic-
acid poisoning, the irregularity of pulse, dyspnoea, &c., com-
mences to increase on the establishment of the drain. In one
case this occurred when the serum sph'ted out of the needle-
holes in an arterial jet, and the bed was soon in a perfect
puddle, and could not be kept otherwise during the six and
thirty hours the patient survived. Still, the puncture or in-
cision is among our armamentaria, and does frequently afford
more or less relief; but the incisions may become troublesome
sores^ or even slough.

Another troublesome sequel of heart failure is increased
flow of bronchial mucus or serum, a chronic bronchitis or
bronchorrhoea. This is not only a result of imperfect nutri-

222

THE HEART AND ITS DISEASES.

tion to tlie respiratory structm-es and consequent formation
of many imperfect epithelimn cells or mucus, but is also a
consequence of congestion of the bronchial veins, and, as
such, gives more or less relief to the distended vessels. It
is thus often useful though troublesome, for it disturbs the
patient's rest and impedes his respiration. Where this con-
dition is marked, a mixture of digitalis, or belladonna with
senega or squill and aether may be prescribed; the two forms
given here are useful, one very palatable, and the other very
effective.

P;. Tiuct. belladonua^, Tit xt.
Sp. cliloroform, 1T1 xxy.
Ac. mur. dil., X(\ x.
Sjr. scillse, 5I.

Aquse ad 3I, ter in die.

^. Tinct. digital., m, x.
Ammon. carb., gr. v.
Inf. senegae, 5I, ter in die.

One caution must be observed in the paroxysms of
chi'onic bronchitis in heart failure as regards prognosis.
Again and again will such a patient alarm all around him,
and even induce his physician to regard dissolution as im-
pending, and in the mornmg — for it is usually in the evening
or early night they come on — fall into a doze, wake up re-
lieved, and go on fairly for some time after. This is, though
a fortrmate termination, sometimes unfortunate for the
physician, m this way : — The alarmed friends sit up all night
and next day — the alarm having passed away — are apt to
regard the practitioner who, however naturally, led them into
error, as w^anting in knowledge of his profession. This acute
pulmonic congestion, with free flow of serum, must not then
be regarded as an accession of acute bronchitis, which w^ould,
in all human probability, be fatal, but be described as a period
of suffering and peril, from which it is not impossible the
patient may emerge. So also may this condition of pulmonic
congestion lead to rupture of the vessels and haemoptysis.
This is often very alarming; but this haemoptysis is not
itself injunous, except by the loss of blood ; and probably in
so severe congestion the loss of blood is necessary, and
could not be so cheaply or effectually furnished in any other
manner. Blood is blood, and whether it is lost by bleeding,
leeches, or ha3mopty6is, it is the same. Haemoptysis is the

TREATMENT. 223

most direct form of unloading the over-charged vessels, and
is not specially injurious, though, of course, it may go on to
a fatal termination, especially when fed by stimulants. But,
ordinarily considered, haemoptysis in heart disease is not
itself a disease or dangerous, but it is a symptom of a very
serious condition ; and it is that condition on which it de-
pends, and not the hsemoptysis itself, which should excite our
fears. It is better, too, not to attempt to arrest the flow
here by sulphuric acid, opium, and acetate of lead, &c , which
certainly disturb the stomach, but to keep the patient per-
fectly quiet. Should the case be very alarming, it may be
desirable to resort to general bleeding.

So, too, when the powers are failing, and the patient
utterly Avorn out, is sleepy to a degree, dozing off for a
moment, and then waking up with a start in terror, and
gasping for breath — even in this piteous condition to ad-
minister soporifics is a moral crime. If the patient sleeps, it is
that sleep which knows no wakening, except in another state
of being. The late Hyde Salter pointed this out strongly.
*' Take away," he says, "the necessity for the voluntary
effort indispensable to respiration, and the patient would
soon be so sound asleep it would be difficult to wake him.
Suspend the voluntary efforts by an opiate, and the sleep is
the sleep of death." However much we may pity the
sufferer, we cannot feel justified in prescribing opium or
other narcotic for a condition which is not sleeplessness, but
where voluntary effort, incompatible with sleep, is necessary
to existence. Nor is chloral hydrate any safer here than the
vegetable soporifics.*

The question of stimulants in the treatment of heart
disease and its sequelae is a difficult one. Where they are
habitually taken, it may neither be desirable nor easy to
withdraw them ; but where they, i.e., alcoholic stimulants,
evidently increase the rapidity and impair the quality of the
ventricular contractions, some attempt must be made to

* Dr. Waters, of Liverpool {Lancet, May 4th, 1872), in a lecture on Hydrate
of Chloral, says, " In cases of heart disease, where there is albuminuria, 1 have
not seen good results from the exhibition of chloral, and I always hesitate to give
it when the kidneys are diseased."

224 THE HEART AND ITS DISEASES.

diminish, at least, the amount. Where a dose of alcohol
improves the pulse and enables the patient to eat and digest
better, its use is indicated. In the most advanced stages,
alcohol is simply indispensable, and forms the chief portion
of what the patient takes. In the less advanced stages, it
is often desirable that the patient take spirit and water
before getting into bed ; it warms him in the cold bed, and
helps liim off into refreshing sleep with less evil effect than
any other agent. The cold of the bed often has a disturbing
effect on these patients. The blood in the skin, chilled by
contact with the cold clothes, excites spasm of the pulmonary
arterioles by its temperature, and thus taxes the right heart.
The bed should be previously warmed.*

External measures are, to some extent, useful — as a bel-
ladonna plaster over the region of the heart, for instance,
which is a favourite measure with many. It is, to some
extent, physically useful ; but psychically it often acts
charmingly, and so may often be recommended with ad-
vantage. As to blisters over the region of the heart to allay
irritability, no modern-educated person would think of re-
sorting to them; as good or better effects having been pro-
duced in the hands of those who do not resort to them as
with those who do, the effect of them may be regarded as
adding a troublesome sore to the patient's troubles, and so
diverting their attention.

The general treatment, in the more advanced cases, con-
sists of food, nutritious and easily assimilable, in small
quantities, and often. Very little or no supper is desirable ;
and patients soon find out that they must make their choice
betwixt suppers and dyspnoea, or the absence of both — the
relation between the two is unequivocal. The morning is

* In discussing the effect of alcohol in arresting or relieving intermittent
pulse — usually a serious indication of heart inability — Dr. B. W. Richardson say8,
'* If after great fatigue, or excitement, or anxiety, there is restlessness, sleepless-
ness, and painful knowledge, on the part of the jiatient, of the hesitation in the
circulation, half an ounce or an ounce of brandy will act, generally, in the most
effective manner. It will bring rest at once, and often, when a narcotic fails,
sleep." Dr. Richardson attributes the efPcct of alcohol in feeble heart on the
brain to its increasing the h(>art's action, and thus supplying the brain with
more arterial blood ; and tlmt it acts as a narcotic by virtue of this action; and
^vi1h this opinion I quite agree.

TREATMENT. 225

the time during which the bulk of the food must be taken.
The clothing must be warm, for the tendency to lowering
of temperature is marked. Exercise must be limited and
exertion forbidden. The bowels must be regulated, and no
straining at stool must be permitted. Death on the night-
chair is not at all uncommon in heart disease. The venous
congestion leads to gastric catarrh, with its pathognomonic
symptom of sense of fulness constantly, and to constipation,
and attention must always be directed to the condition of
the intestinal canal. The bladder must be examined occa-
sionally, and, if involuntary dribbling exists, a catheter must
be used ; for, as Sir Henry Thompson insists, involuntary
micturition is the evidence of a distended bladder and not of
an empty one. This attention to the bladder is more neces-
sary, as prostatic enlargement is common in elderly men,
who are also often the subject of heart disease. But there
is another reason, and that is, that, in consequence of the
venous congestion of the brain, the patient becomes altered
in his cerebral manifestations, and not unfrequently his
habits change somewhat. This effect of congestion of the
cerebrum and its mental consequences are more frequent
than is generally thought. The patient has a tendency to
become petulant, whimsical, and childish, and must be
treated with great considerateness. The appetite is often
capricious, and must be humoured as far as is safe. The
whole management of the sufferer from heart disease of an
advanced type is especial, and consists of a union of judicious
finnness, perfect openness, and infinite patience. The patient
must be made as clearly aware of the nature of his case as
is possible; and in those cases where the patient positively
declines to know anything about himself, the friends should
have the case explained to them, for his guidance, as to what
he must do and what he must avoid, and why and wherefore.
For, if the case is a prolonged one, everything to facilitate a
good understanding and perfect mutual confidence must be
cultivated ; for this mutual confidence will many a time and
oft be strained, partly by the oscillations of hope and despair
in the patient, but more frequently from the interference of
others.

Q

226 THE HEART AND ITS DISEASES.

Intercurrent disease of every kind, and especially bron-
chitis, which taxes the heart dreadfully, is attended with
more than ordinary danger, and special attention must be
paid to the heart, and measures taken to sustain it, or the
patient Avill surely die. Finally, every case is a subtle
problem to be solved ; whether it is in that stage that
recovery or repair is possible, or in that more advanced con-
dition where treatment can only be regarded as a means of
procuring more perfect euthanasia. When, however, the
tricuspid becomes obviously affected, whether early on in the
case or after a long period, the case passes quickly into the last
category. Here no means of acting on the heart itself can do
much, and that little only so long as the veins will or can
sustain the pressure thus increased. Relief of the venous
congestion, by acting on the various emunctories, is all that
we can fairly hope for here ; and whatever measures be
adopted,, it is not for long. Whatever hopes of prolonged
life had previously existed must be given up, when the
tricuspid lesion becomes marked ; and from the last division
of treatment alone can anything almost be expected.

AFFECTIONS OF THE PERICARDIUM. 227

CHAPTER XI.

Affections of the Pericardium : Acute Pericarditis —
Pathology — Symptoms — Treatment — Pericardial Ad-
hesion— Hydropericardium, &c.

The pericardium or serous sac of the heart is occasionally
congenitally wanting. It consists of two layers, an external
and internal one ; the latter, closely investing the substance
of the heart, extends upwards nearly to the top of the aortic
arch when it becomes folded back, and forms the external
layer. This serous sac enables the heart to perform its
necessary movements without friction, and may contain
normally a small quantity of fluid. This serous nature
renders it liable to inflammations of both an acute and chronic
character, especially in connection with general constitutional
conditions. Various chronic conditions result from acute
inflammation, from the formation of fibrinous bands betwixt
the two pericardial layers up to complete adhesion. In other
cases the eflusion persists and assumes some chronic form.
The pericardium may also be the subject of passive exuda-
tion without inflammation at all ; this is hydropericardium.

Acute Pericarditis. — This is not an uncommon affection,
and has attracted a great amount of attention from the
majority of observers, in consequence of interesting pecu-
liarities in its course. When the pericardium first becomes
inflamed it presents the appearance of general redness with
ecchymosed points, often of a tree-like character. There is
swelling in the serous and subserous coats, and the formation
of delicate, villous projections and effusion of a serous fluid
usually containing shreds and filaments of lymph. This
fluid varies in amount and quality. Frequently it is in con-
siderable amount and distinctly fluid ; at other times it is
more decidedly albuminous, and so dense as almost to possess
consistency, and the two layers are adherent. When

Q 2

228 THE HEART AND ITS DISEASES.

separated, tlie surfaces present a honey-combed appearance,
or, indeed, extremely like " tripe," and are not at all unlike
two buttered surfaces when applied to each other and then
separated. At other times, and when associated with dys-
crasial affections, the exudation is bloody and then the peri-
carditis is termed heemorrhagic.

Pericarditis has various terminations, and is rarely itself
a cause of death. Absorption may take place and extend to
a restitutio in integrum. While the fluid is absorbed, in other
cases the fibrinous shreds form bands which bind the two
layers of pericardium together, but, being dragged on by the
heart's movements, in time fibrinous bands are formed like
pleuritic adhesions. At other times the adhesion is more
general, and may extend to a complete adhesion of the two
pericardial surfaces and obliteration of the pericardial cavity.
The effused fluid in other cases itself undergoes changes, or
may even remain simply unabsorbod. The fluid may become
purulent and resemble the contents of the pleuritic cavity in
emphysema. Under these circumstances, perforation appa-
rently by abscess may occur through the chest walls, and
thus may be added pneumopericardium, with the formation
of ichorous pus. But more commonly, while the fluid con-
tents of the sac may be absorbed, the more solid ones remain
and undergo various changes. The lymph may undergo
fatty degeneration, and remain in cheesy or even mortar-like
masses, or the more fluid parts of the degenerated mass may
become absorbed, and chalky masses remain. These earthy
constituents may, along with certain connective tissue cor-
puscles, become more or less organised, and an ossification,
or perhaps more truly, petrifaction may result. This may
even be general, and the heart be enclosed in a calcified
outer coat instead of its serous coverings.

The pericardium may, like other serous surfaces, become
the subject of grey or miliary tubercle, and be studded with
it. It may even have deposits of the larger masses of
yellow tubercle.

In connection with pericarditis must be mentioned the
" milk spots," or " white patches " of the heart, which were
at one time thought of some importance other than patho-

AFFECTIONS OF THE PERICARDIUM. 229

logical. They were supposed, from their frequency in
soldiers, to result from the " cross straps " which traverse
the region of the heart, and were accredited with causing the
deaths, or at least aiding in causing them, of those in whom
they were found. But more careful investigations have
acquitted them of any dangerous or lethal properties, and
they are now known to be very innocent growths of white
connective tissue immediately beneath the cardiac pericar-
dium, utterly free from any effect upon the tissues below
them.

Pericarditis is usually accompanied by more or less ex-
tension of the inflammatory process into the muscular struc-
ture of the heart. This may extend more or less deeply, but
is usually superficial, and is denominated myocarditis acuta
parenchymatosa. At other times it extends sufficiently to
cause yielding of the heart fibres and the formation of dila-
tation. This may result fi'om the muscular fibre becoming
infiltrated with serum, without necessarily true carditis
having extended through the muscular wall.

Very commonly, too, endocarditis is found along with
pericarditis, but they cannot be regarded so much as the
result of one another, as the results of some exciting force
common to each as a provoking cause. The external layer
of pericardium may become affected simultaneously with
pneumonia or pleuritis, one running into the other by con-
tiguity.

Oppolzer divides pericarditis into four divisions : —

1 . Idiopathic, or simple, in which it is unconnected with
any constitutional condition. A precisely similar state
occurs in the rare cases where it is traumatic in its origin.

2. Consecutive, where it is consequent on some previously
existing affection, and has spread by contiguity as when it
results from pneumonia, pleuritis, necrosis, or caries of the
sternum or ribs, spinal caries, aneurism, &c. ; from tubercu-
lous masses or cavities in the lungs, abscesses, &c., or, indeed,
any condition which may lead directly to inflammation of
the external layer ; or from myocarditis which may lead
to changes in the internal layer first.

3. Symptomatic. In this division are placed those in-

230 THE HEART AND ITS DISEASES.

flammations of the pericardium which accompany rheumat-
ism, Bright's disease ; zymotic affections, as typhus, small-
pox, scarlatina, cholera; constitutional conditions, as tuber-
culosis, sypliilis, chronic alcoholism, &c.

4. Metastatic, where it is associated with most of the
conditions under the preceding division, especially the
zymotic conditions, and in addition pysemia and puerperal
fever. The pericarditis of these last conditions is necessarily
of a serious character partaking of the general condition.

Pericarditis is frequently associated with scurvy and with
purpura, and when so occurring is of the hsemorrhagic
character. It has even been found in an epidemic form in
Russia, where apparently diseases not usually regarded as
epidemic have a tendency to so become, as cerebro-spinal-
meningitis, &c. Not uncommonly will be observed epidemic
outbreaks ; undoubtedly is this the case with hasmorrhagic
pericarditis, which has been observed by Russian physicians,
on the shores of the Baltic sea, in great frequency in preva-
lent attacks of scurvy (von Dusch).

But, as commonly and ordinarily seen, pericarditis is
found in connection with rheumatic fever. It usually does
not manifest itself for some days after the establishment of
the fever with its joint affections ; at other times it may arise
simultaneously with it, or even in some cases precede it. In
these latter cases it may form all along the most marked
part of the ailment, and it has even been asserted that true
rheumatic pericarditis may occur without joint complications
at all.

The proportion of cases of pericarditis with acute rheu-
matism has been variously estimated from so low as 16 per
cent, to as high as 75 per cent., the proportion of recoveries
being closely allied to this, for where pericarditis is associated
with rheumatism it is much less serious than when alhed to
dyscrasial conditions. Most elaborate tables as to the con-
nection of pericarditis with acute rheumatism have been
di'awn up by Fuller, and those who wish to enquire further
into tliis subject may advantageously study these tables in
his well-known work on " Rheumatism, Rheumatic Gout, and
(Sciatica."

AFFECTIONS OF THE PERICARDIUM. 231

Pericarditis is rather a complaiut of cold weather than of
warm weather, and, so, is supposed to be associated with cold,
but the connection is not very evident. It is found more in
men than in women, but whether the conformation of the
female bust has anything to do with this, or not, is not
known. It is common in the early years of puberty, and, as
associated with rheumatism, is a disease of early life rather
than of advanced life. As connected Avith dyscrasiee, it is
common in more advanced life and in adults.

Pericarditis is a somewhat difficult affection to describe, as
regards its symptoms, in consequence of its being so rarely
found disassociated from other ailments. Still a more or less
approximative description may be given of it. It is usually
preceded by rigors, but these are not so marked in con-
sequence of its associations. Its first symptom is usually
pain over the region of the heart, not excessive, unless there
be also pneumonia or pleuritis, and at times entirely wanting.
Still ordinarily there is pain increased by deep pressure.
The patient is usually flat on the back, an attitude probably
rather due to the general affection of the joints than to the
pericarditis. There is a plaintive look of suffering, and of
desire for succour, somewhat characteristic. The pulse is
accelerated, and at first to some extent bounding, but this
characteristic is soon lost, and the pulse soon becomes weak,
compressible, occasionally very rapid, at other times not so
accelerated, and it is even sometimes delayed; it has a
tendency to become irregular, and is ever disproportioned to
the apparent activity of the heart. In fact there is often
palpitation and considerable cardiac excitement in the
earlier stages, but these are merely evidences of cardiac
inability. There is decided depression, that is the prevailing
characteristic. There are also headache, dizziness, tendency
to delirium, especially at nights, and sometimes very active
delirium ; the countenance is usually injected, and the lips
blue. There is increase in temperature, usually not exceed-
ing 104°, but this is a doubtful point also, in consequence of
the usual complications. In the latter stages of the fatal
cases the temperature may fall below the normal. There is
often gastric derangement, in consequence of the unity of

232 THE HEART AND ITS DISEASES.

the nerve supply. The nrme is small in quantity, usually
laden with lithates, and often very free from chlorides, and
this, too, is not cojifined to cases where the lung is impli-
cated ; it is often, too, albuminous. There are some peculiar
points of interest in pericarditis as regards its symptom"
atology, to which we will return, and also some curious
simulations by it which need notice.

The objective symptoms of pericarditis are the most cha-
racteristic points in determining its existence and in separat-
ing it from conditions which might be mistaken for it. Indeed,
in all cases of acute rheumatism it is imperative every day
to examine the heart for physical signs, for all rational symp-
toms may be absent, or masked. The pain, indeed, may be
forgotten by the patient, or masked on account of the ex-
cessive pain in the joints, and so also may the palpitation not
be noticed.

To inspection there is rarely any sign to be noted, unless
the latter stage of effusion be reached, and then it is not
easily marked in the adult, though a bulging forward may be
discernible enough in the younger persons, whose costal
cartilages are yet unossified. Usually in the earlier stages
tij^re is no evidence furnished to inspection.

To palpation, however, it is very different. The cardiac
excitement in the first stages is to be felt by the hand, and as
soon as there is friction betwixt the two dry, inflamed, and
roughened, surfaces, this is palpable to the hand. In fact, we
may feel the friction murmur, which is manifest to the ear.

This of course may be more or less distinct, according to
its extent. When there is effusion this of course is lost, and
the heart's action becomes faint or imperceptible. This,
however, may not depend entirely on effusion, but may be
due to the loss of tone in the heart, and the feebleness of its
action.

Percussion gives us no aid in the early stage, except
negative evidence of no increase in dulness, or the absence or
presence of lung complication. But as the effusion increases
percussion becomes of more service ; still, like all percussion
about the heart, there are many sources of error. At first,
when the effusiou is limited, it is confined to the upper portion

AFFECTIONS OF THE PERICARDIUM. 233

of the pericardium, the heart occupying the lower portion ; and
here many sources of error come in, as aneurism, tumours, &c.
But as the effusion increases, the dulness assumes a pyriform,
or triangular shape, the triangle standing upon one of its
sides. This dulness becomes broader when the patient lies
down and is less extended laterally when sitting up or
standing up.

This dulness is not unlike that of right side enlargement,
and there is more difficulty in distinguishing it by reason of
this fact, that the right ventricle is often dilated from the
effects of the effusion on the muscular fibre. There is one
point, however, which is always of value in making the diag-
nosis, and that is in right side enlargement there is never
dulness extending beyond the left apex laterally. Now, in
pericardial effusion the dulness does extend to the left of the
left apex, and may usually be so detected as deep seated dul-
ness. This will always settle the question, but unfortunately
the intervening lung is a sadly disturbing element. The
lung may be consolidated, and thus give an impression of
extended lateral dulness, or it may be highly resonant, and
mask it, or it may be tied down by adhesions, and prevent
the changes in amount of dulness ordinarily elicited by testing
during a deep inspiration and full expiration. Ordinarily,
however, percussion is of great service in determining the
amount of effusion, and the errors are corrected by the other
means of examination.

Auscultation. — To this means of examination we owe most
of our positive information as to the existence and extent of
pericarditis. By it we detect and localise the friction mur-
mur which is characteristic of pericarditis. This friction
sound (Beibungsgerausch) is produced by the attrition, the
rubbing together of the dry inflamed pericardial surfaces. It
is of a decidedly " to-and-fro " character, and is systolic and
diastolic. It is usually in proportion to the amount of inflamed
surface, and where this is limited may only be heard over a
small area. This area of audibility is of importance then in
aiding us in knowing to what extent the inflammation has
spread. So, when the inflammation has extended over all
the surface, the murmur is general, and heard equally dis-

^34 THE HEART AND ITS DISEASES.

tinctlj in all parts. There are, however, difficulties iu the
way here even, and it is often well nigh impossible to dis-
tinguish a pericardial murmur from the murmur of endo-
carditis so often found along with it, and under similar
circumstances. Even the " to-and-fro " character may not
be pronounced enough to determine the question, though
usually sufficient. When this is the case, the locality of
greatest intensity is of great moment, for the endocardial
murmur is almost invariably left sided, and if the murmur is
heard over the right side of the heart, it is almost certainly
pericardial. The murmurs have to be compared otherwise,
and Dr. T. King Chambers in his Clinical Lectures advocates
strongly the plan of applying the ear to the stethoscope,
finding the murmur, and then withdrawing the ear gradually
from the stethoscope, retained m situ, noting the persistence
of the murmur. If heard as long as the heart sounds are
audible it is endocardial ; if lost while the heart sounds are
still audible, it is pericardial. How far this is correct, and
has been tested absolutely by the records of the dead-house,
I am not in a position to say. It needs investigation.

One thing, however, does not admit of much doubt, and
that is that all examinations of the chest, when inflammatory
affections of thorax accompany acute rheumatism, should be
as brief as is possible and compatible with due care. For the
exposure of the chest for any time is always followed by in-
creased pain, distress in the countenance, and general
increased discomfort.

It is to be feared that some pericardial affections have
taken their immediate origin in the assiduity with which they
are sought for, especially in Germany.

Not uncommonly a difficulty arises as to the friction sound
being pericardial or pleural. This can be easily determined
by makmg the patient hold his breath, when the pericardial
sound can be distinguished. Also when there is accompany-
ing pleurisy or pneumonia, the disturbing element can be
always so eliminated.

These various measures, along with the subjective symp-
toms, will usually enable the medical observer to form a
correct diagnosis ; but it must be admitted that many peri-

AFFECTIONS OF THE PERICARDIUM. 235

cardial inflamniations first reveal themselves to the scalpel.
In addition then to the objective symptoms, and the brief
account of subjective symptoms given above, some of the
more especial points of pericarditis may be discussed. The
general depression, especially of the pulse, and its tendency
to halt, has been referred to the irritation of the cardiac
ganglia, but of this we have no proof ; while the evidence is
not far to seek that when there is eflfasion there is pressure
on the heart which must interfere with its action, and is
sufficient occasionally, when persistent, to induce atrophy of
the substance of the heart itself. The extent, too, to which
the myocarditis, or even infiltration of the muscular walls,
has proceeded, must much affect its power. The difficulty of
breathing is also due to vascular congestion of the lungs from
the retarded circulation, and perhaps partly to the pain
induced thereby from the motion. There is also oppression
of the chest and sinking. How far these are all due to the
inflammation affecting the large congeries of nerves in the
neighbourhood of the pericardium it is difficult to say, but
some of the peculiar manifestations of pericarditis are cer-
tainly due to its involving nerves in its neighbourhood. For
instance, from its action on the phrenic we get the persistent
and troublesome hiccup not unfrequently observed. Indeed,
it may go so far as to produce complete paralysis of the
diaphragm, with falling of the abdomen on inspiration.

It is probable, too, that the inflammation of the portion
encircling the aorta may lead to effects upon the numerous
nerves there, and produce those gastric symptoms which
sometimes entirely take the place of all pericardial symptoms.
Acute gastric symptoms have been found to owe their origin
in pericarditis, which had been utterly unsuspected previous
to the physical examination.

But it is as head symptoms that these irregular manifes-
tations of pericarditis have been most frequently observed.
Again and again have all the symptoms of meningitis been
simulated by pericarditis. This is of more moment in diagnosis
in that rheumatic metastases to the encephalon are not un-
known, and are unfortunately almost invariably fatal. Thus
it is of great importance to ascertain whether such be really

236 THE HEART AND ITS DISEASES.

the case or there is only pericarditis to deal with ; for serious
as is pericarditis, its fatality is small. There is often acute
and wild delirium, and indeed all the symptoms of early
meningitis, unless it be ophthalmoscopic ones, and of this we
as yet know nothing. The head symptoms often allay all
suspicion of anything, but meningitis and the recognition of
some sign by which suspicion may be aroused is important.
Austin Flint has given this subject careful investigation, and
relates two cases at length. Both were typical cases of
meningitis, simulated by pericarditis, and in both he observed
a peculiarity in the delusion of the delirium. This was the
fixed impression of having committed some crime. He says,
*' a fixed delusion of having committed some crime appears to
be a distinguishing feature " (p. 358). This point may turn
out to be of practical value in directing attention to the
possibility of pericarditis in cases of apparent meningitis. Not
only is the prognosis affected by the distinction, but treat-
ment is also directed from a wrong to right neighbourhood.

Terminations. — As might be readily supposed from the
position and function of the pericardium, and the various
forms of pericarditis, the results of it and its terminations
are also varied. Thus the inflammatory action may cease
ere the stage of effusion is reached and a complete remission
takes place. Or if the fluid contain little or no fibrin, a resti-
tutio in integrum is possible. In other cases the fibrin forms
bands ; or a complete obliteration of the pericardial cavity
may, and not rarely does occur, forming what is called
''adhesion of the pericardium," a condition frequently not
incompatible with some years of life, and which must be
considered separately. The fluid may remain, and even
become puriform, and open like an abscess ; or the more fluid
parts may become absorbed, and the solid parts undergoing
degeneration become cheesy-like masses, &c.

The effect upon the heart itself varies also. The pressiu-e
of the effused fluid may lead to atrophy. The infiltration
into the muscles usually leads to dilatation at the time, which
may remain in unfavourable cases, but in others is often
followed by hypertrophy, which re-endows the patient with
a ftiir share of power and vigour. The adhesions, and more

AFFECTIONS OF THE PERICARDIUM. 237

SO if complete, may by incommoding the heart's action, lead
to hypertrophy, or in other cases to degeneration and failure.
The myocarditis which often accompanies pericarditis may
lead to destruction of tissue and heart scars, or contractions.
Finally Rokitansky tells us that adhesion may take place
along the track of the coronary vessels, and, by constricting
them, cut off to a large extent the blood supply of the heart,
and lead thus directly to fatty degeneration.

Prognosis, — In forming a prognosis on so difficult a matter
as pericarditis great caution and circumspection is imperative.
Not only must the amount of inflammation and its imme-
diate complications be considered, but its causational rela-
tionships must be carefully weighed. For these afiect the
prognosis most materially, not only as general conditions
themselves, but as also aflecting the nature of the effused
fluid. The nature of the effusion obviously is of great
moment in forming the prognosis, and where it is haemor-
rhagic, or purulent, there is a much worse prospect, infinitely
worse, indeed, than where there is mere serous fluid with
shreds of lymph. Of course the issue of the pericarditis
hangs greatly on the nature of the accompanying affection in
many cases, and in pyaemia it is of little moment how favour-
able the pericarditis may be in itself, the condition with which
it is allied, or rather on which it depends, is one admitting of
little hope. Each case must, from a prognostic point of view,
be regarded in relation to itself and its surroundings. But
pericarditis accompanying dyscrasial conditions is ever grave
and serious, while the pericarditis which accompanies rheu-
matic fever is rarely fatal. Such changes may, indeed, be
inaugurated as are soon incompatible with life, and in this
lies the sthig of both endocardial and pericardial inflamma-
tions. The patient rarely dies in these rheumatic inflamma-
tions at the time, but lingers, crippled and wounded, through
a more or less brief period of suffering until carried off by
the secondary affections.

Treatment. — The treatment of pericarditis is indeed a
tangled skein, for while we have still hanging over us the
shadow, and often perhaps something more substantial, of
the old heroic practice, we are entering a phase of compara-

238 THE HEART AND ITS DISEASES.

tive scepticism, or even, perhaps, a new phase of mischievous
remedial interference. It is somewhat difficult then to indi-
cate a line of treatment which will steer clear of both old
and new dangers. General bleeding for the relief of this
condition is now universally abandoned, nor can we feel sur-
prised when we regard the great tendency to depression
which is the main characteristic of the complaint. So also,
almost universally, is the application of a blister, which was
once applied under some impression that it allayed the irri-
tability of the heart. It is possible that the effusion from
the cutaneous branches of the internal mammary relieved
the pressure on the internal distribution, and so tended to
starve the inflammatory process ; but the addition of the
sore and its being in the way of other applications after are
positive disadvantages arising from its use.

Leeches are often applied to the skin over the heart, and
in strong persons this mode of relieving the fulness of the
cutaneo-pericardial distribution is to be recommended. Dry
cupping is also admissible with a similar intent ; but the
most favourite and imiversal application is the large hot
linseed poultice, with or without a facing of mustard. This
also acts on the cutaneous vessels, dilates them, and relieves
the deeper distribution. It is effective, can be continued
persistently, and does not act prejudicially on the skin, and
thus interfere with the adoption of other measures, if they
are indicated. The poultice should be large, and removed
ere cold, for the occasional removal of a cold poultice by a
warm one is most reprehensible. The effect of this appli-
cation in relieving the pain and in diminishing the evidence
of inflammation, the friction-murmur, is often most gratifying ;
and for those who are in general practice, and can only see
their patients on somewhat distant intervals, it will be found
a most excellent practice to leave directions with the nurse,
in all cases of acute rheumatism, to apply hot poultices as
soon as ever the patient complains of any pain in the chest,
and to keep them applied till the return of the medical
attendant. There is good reason to believe that the early
application of hot poultices arrests many a pericardial inflam-
mation at an early stage. Of course as to general treat-

AFFECTIONS OF THE PERICARDIUM. 239

ment, much depends on each man's way of treating rheu-
matic fever, and this is not a subject affording strong evidence
of medical unanimity. But certainly the patient should be
clothed in a flannel night dress, or, among the poor, a man's
flannel day shirt comes in very handy ; and sheets ought to
be dispensed with and the blankets kept well about the chest.
Nothing is so bad as exposure of the chest, or arrest of the
general perspiration. Consequently purgatives are distinctly
contra-indicated, not only from the risk of starving the
patients, for with some persons it is well nigh impossible to
empty either bladder or bowels in the recumbent posture,
but also from the disturbance entailed and its effect in increas-
ing the rapidity of the circulation. Diaphoretics are in
general use, and so are mild opiates to relieve the pam; the
combination in Dover's powder has a wide-spread popularity.
In strong persons, a few, from three to five, grains of James's
powder, or of pulv. antim. co., may be added to the ten grains
of Dover's powder usually exhibited at the hour of retiring
to rest. The old rule of Graves is one well worth remem-
bering in the administration of the vegetable narcotics, viz.,
to give the dose at such a time that the exciting action may
have passed away, and the narcotic action come into force at
the usual habitual time of sleep coming on. To catch this
natural hour of sleep so that habit and the action of the
remedy may unite, and not clash, is a golden rule in the
administration of soporifics. If the reader has not already
formed a positive opinion on the treatment of acute rheu-
matism, it may not be out of place to state that the evidence
brought to bear by Fuller, in his work on Rheumatism, in
favour of the alkaline treatment, both as regards its efiect
on the duration of acute rheumatism and its efficiency in
averting cardiac complications, is worthy of great attention.
It is, perhaps, the most common treatment, in England at
least, and has been adopted by the writer. From one to
two scruples of bicarbonate of potash, with ten or fifteen
drops of tinct. opii in serpentaria or buchu every four or six
hours for an average adult, is a good plan. The amount of
opium here is not excessive, in the face of the pain of the
inflamed joints, and when given with an alkali it is not so

240 THE HEART AND ITS DISEASES.

active as when given alone or with acids, while it is a most
effectual diaphoretic. It is well, too, to dilute the medicine
by a good drink of fluid after it ; this aids in the absorption
through the walls of the stomach. The joints may be
wrapped up in flannel gently wrung out of a solution of
potash and laudanum, and applied in strips wet enough to
stick to the skin, but not so wet as to be sloppy.*

These measures with a milk diet, or mixed with beef tea,
will ordinarily be found efficacious and satisfactory. As soon
as the activity of the attack is over, the potash may be some-
what reduced in quantity, and some potassio-tartrate of iron
added. The usual plan of treatment of convalescents by
tonics, good diet, and cod-liver oil where necessary, may be
followed here, and needs no comment, unless it be to always
push the treatment, when any of tbe joints of the hands
swell and are. painful ; to lose time then is unfortunate. If
the threatened\pericardial affection be altogether averted, or
pretty effectually restrained by the measures adopted, the
case usually progresses favourably to complete recovery.

Before, however, proceeding to describe the treatment of
remaining effusion, it is almost necessary to say a word on
the German plan of the application of ice to the precordia or
pericarditis. We could almost tell previous to applying it,
that this contraction of the cutaneous branches, so induced,
would tend to drive the blood in greater force into the in-
ternal distribution. This may relieve the pain and place, as
Hilton calls it, the inflamed pericardial surfaces in physiolo-
gical rest, by separation, but it may be gravely questioned if
this is a result to be wished for. Certainly the numerous
cases of death produced from the consequences of cardiac
complications of acute rheumatism, in young persons, to be
seen in the Pathological Institute of the Vienna Krankenhaus
are not very convincing arguments in favour of the plans of
treatment adopted. Niemeyer says " Calomel and blue oint-
ment, in spite of the praise of English physicians, are not
only useless, but hurtful." While admitting to the full the
probable truth of this, I must also be permitted to most
gravely call in question the plan he recommends of the appli-

* The blister treatment of Herbert Davies is also largely adopted now.

AFFECTIONS OF THE PERICARDIUM. 241

cation of cold. The results are not by any means gratifying,
and several who watched this plan in the Belle vue Hospital?
in New York, inform me that its results were decidedly un-
satisfactory.

The practice originated in the good results sometimes
observed from the application of cold to the chest in haemo-
ptysis. But the anatomical relations of pericarditis and of
haemoptysis to an ice bladder on the chest are too different
for similar results.

Where there is great depression and the pulse is failing,
with other evidences of depressed circulation, both Niemeyer
and Oppolzer recommend strongly the administration of
digitalis ; and certainly its use under these circumstances is
clearly indicated, along with stimulants and tonics.

Where effusion remains in the pericardial cavity, the usual
measures are diuretics, purgatives, and the internal adminis-
tration of iodine.

The measures are commonly successful, and are usually
combined with the application of blisters over the cardiac
region. The use of blisters at this time is attended with
more favourable results than when applied during the acute
inflammatory stage. It has been seriously disputed whether
the absorbent action is during the healing of the blister, or
continues during the time of the sore, which has therefore
been artificially prevented from healing. The more usual plan
is to apply a blister, and repeat it when the surface has
healed. The old cantharides blister was used, but now the
stronger preparations of iodine are preferred, for various
reasons.

These measures, however^ may fail, and the pressure on
the heart may demand that some operative procedure be
resorted to.

For evacuating the fluid directly, the operation of para-
centesis pericardii has been resorted to, and that, too, success-
fully. Dr. Clifford Allbutt has advocated this plan, and set
the example of resorting to it in practice. From the ten-
dency to the formation of ichorous pus on the admission of
air into the pericardium (pneumopericardium), the extraction
of the fluid by suction, as by the pneumatic aspirator, so as

R

242 THE HEART AND ITS DISEASES.

not to admit of the entrance of air, is desirable. It is not,
however, a proceeding to be Hghtly undertaken, and on one
occasion at least, and in competent hands too, it is recorded
that a dilated heart was itself tapped. This shows how
difficult it is to ascertain exactly the position of parts within
the distended pericardium, and how carefully must the ex-
aminations be conducted previous to inserting a trocar into
the thorax in the cardiac region.

Still, the practice is one which is likely to be more largely
adopted, as, when serous membranes have once been changed
by inflammation, they do not readily put on again acute in-
flammation, which used to so alarm our predecessors in
attempting any measures which might excite inflammation of
a serous membrane. For the relief of purulent pericarditis
older surgeons have even trepanned the sternum, and that,
too, successfully.

For the treatment of pericarditis occurring in dyscrasial
conditions, it is difficult to arrange anything like a rule. It
must here so obviously depend on the condition along ^vith
which it occurs, that any special treatment is well nigh im-
possible, and any local treatment even must be dependent
on the treatment of the general condition. Stimulants must
be largely resorted to after effusion is established, but during
the dry stage it is doubtful, if any good could counterbalance
the increased rapidity of the pulse and the increased friction
thus necessarily entailed.

Pericardial Adhesion. — One of the common consequences
of pericarditis is adhesion of the pericardium, a condition how-
ever not incompatible with a more or less prolonged existence.
The amount and extent of adhesion are varied, and exert a
decided influence over the progress and prognosis of the case.

The adhesion may be partial, and consist of one or more
adhesions drawn, by the heart's action, into bands, and re-
sembling pleuritic adhesions.

There may be adhesions dividing the pericardial cavity
into loculaments containing fluid or other contents.

The adhesion may be complete, and the pericardial cavity
completely obliterated.

Tliis adhesion may be complete, and also contain the

AFFECTIONS OF THE PERICARDIUM. 243

chalky debris of the fibrin of the pericarditis, or a sort of
union may have taken place with some connective tissue
corpuscles and a calcified ring, apt of old to be termed ossi-
fication, may be formed.

This adhesion may extend to the costal pleura ; and under
these circumstances only are there any objective symptoms of
its existence.

These difierent forms of adhesion exercise different effects
upon the muscular structure of the heart itself. The chief
changes are hypertrophy in favourable cases, and in good
nutrition, by which the incommoded heart is able to fulfil its
function for some years fairly efiiciently. In other cases the
tendency is to dilatation where there is not perfect adhesion,
which would tend to prevent it.

In other cases, however, the muscular fibre is discoloured,
pale, and the subject of fatty degeneration. There are rarely
wanting traces of myocarditis with its scar-like depressions.
There is also a tendency for the inflamed pericardium to ad-
here along the track of the coronary vessels, and when this
occurs there is rapid and extensive degeneration of the
muscular structure from the diminished blood supply.

Symptoms. — The subjective symptoms of adherent peri-
cardium depend solely on the condition of the heart with
which it is associated. Where there is fair hypertrophy, the
patient may exist years without any evidence of its presence.
Thus Stokes had a case which existed seven years without
any evidence of its existence. But the cases where it is ac-
companied by evident degeneration of the heart wall are also
accompanied by evidences of heart failure. These are, diffi-
culty of breathing easily aggravated, evidences of general
venous congestion with injected countenance, abdominal ple-
thora, and dropsy in time. There are, too, attacks of angina
pectoris. Thus, though there are no positive subjective symp-
toms, when these symptoms follow after general pericarditis
and regularly increase in severity, there is presumptive
evidence that pericardial adhesion exists.

Objective Symptoms. — When the adhesion is confined to
the pericardium solely, there are no objective symptoms to
be relied upon by which it may be recognised. Skoda says,

R 2

244 THE HEART AND ITS DISEASES.

" no symptoms are discoverable, through percussion and
auscultation, which can be ascribed to adhesion of the heart
and pericardia." Nor to their auxiliaries, in examination, is
much divulged. It has been stated that there are loss of
apex-beat, and where still observable, no changing of its
seat on change of posture or movement of body ; but these
are to be entu^ely relied upon for a diagnosis.

When, however, the pericardium is adherent to the costal
pleura, there are signs of this which are of positive value.
The adhesion to the pleura furnishes to inspection a retrac-
tion of the intercostal spaces on each systole. The heart
becomes shortened on each systole, and so the intercostal
space is dragged inwards on each contraction, and expands
again when the heart becomes longer on diastole. To pal-
pation too is felt this retraction along with what Hope called
a ''jogging motion" of the heart. This sign is regarded as
of some value. Bouillaud says, " On sent a la main que la
jeu du coeur est embarrassee."

To percussion, too, there are some signs, the most im-
portant one being the non-alteration in size of the area of
percussion dulness in expiration and inspiration in comparison
to the normal.

Pi'ognosis, — The prognosis of pericardial adhesion is hope-
less as to cure, and bad as to duration of life. When it is
positively diagnosed, a doubtful existence is all that can be
hoped for, and the consequences of it upon the heart walls
will show themselves sooner or later. But when it is accom-
panied by presumable hypertrophy, as evidenced by a fair
pulse, good general health, and fair physical power, it would
be rash to hazard any opinion as to the probable duration
of life. When once evidences of tlie degeneration of that
hypertrophy show themselves, no great prolongation of
existence is probable, or can be hoped for.

Treatment. — The treatment of this condition does not
consist in any attempt to affect the adhesion by any agents,
but merely in attending to the symptoms which show them-
selves, and in the appropriate measures for preserving a fair
condition of the muscular walls. Thus exercise and exertion
must be limited so as not to tax the embarrassed heart, while

I

AFFECnOXS OF THE FERICARDiriL ±4^5

nonrislmi^ diet, prepaiaticHis of iron, &c^ are skbeotat^j
nece^arv. For evidences of heart ^dhae the same measures

m

must be resorted to as when tliej occur without paicardial
adhesion.

Hijdropericardium. — Hydropericardiom or the eflfbeifHi of
senmi into the pericardial sac is a non-inflammatorjr cank-
plaint, and is not to be confounded with the effbaon ItJlow-
ing- acute pericarditis. It is not associated with any
inflammatory process of a chronic <^iaracter, bat is a serous
effusion depending- on cardiac or renal disease. It is a mra^
effosion without lymph, and when abscnbed lea^'es no trace
behind it. It has at various times been chemically examined,
and a recent analj^is by Wachsmnth grres the following
result: —

In each H» part of effusion —

Water from 95-37 to 97-34

Fixed material from .... ?'66 to 4:'63

AXbumen from 1 13 to 3-tJl

Other material fix>m ... 1'23 to I'dl

It is often extensive in : mn^ity. and is a source of dis-
tress to the patient, * r r. " -i— -V a sonrce rf
danger. In consequen-e : ^ _ t -. ^^^ ^^ " —:

does not usuallv amount : _ it - _ z-z :, c_n :.

m

though it may amount to ' ir r ~\^^ I'TT-h : sm ~ -

tities below an ounce cun - : t_; t . ?:? r:i^l

Thr T^eet of this ffmd upon t_
emlej-r3.ss its action, wliile tte heart filse itself is
easily torn. This does n-i" : :70m any dr^TUT
much as infiltration with serum an : ini^ _ _ : rn :e. It

may by pressure lead to diminuti \ ^ z _ ' ^ t _ ■

itself but that is rathera result of tie tz
The felt of the heart, how^ever. ♦lis
the duration of the effusioz ^ '~

The conditions under w_,_ > : —

1. Scarlatina. It is a mc^st _ --.__:. -^: of the

oedema ^which fi^etjuently foUowa - : fever. This depends

on the Wocking up of the renal urinifer»>us tubdes with
epithelial casts in the desquam-:itive st^^ge of the tubular

246 THE HEART AND ITS DISEASES.

nephritis which usually accompanies scarlatina. It comes on
insidioiislv, and is ordinaiily found along with pleural eflFu-
Bion. It is entirely a passive exudation, and is soon real>
sorbed on the renal floTv beiag again established.

2. Briirhts Disease. It is also by no means rare in the
latter stasres of chronic kidnev disease where there is dif-
fused oedema. Xo attempt has been made to show that
under these circumstances the fluid contains urine salts,
though it is not improbable. When occuiring in Bright's
disease is more serious and more obstinate than in the pre-
ceding division, and altogether indicates a more serious
condirion.

3. It is also found as a result of chrom'c heart disease,
and then, like most serous effosions, is only found in the
latter stages of the case. Its presence here by further em-
barrassing the already failing heart is a very serious matter,
and adds much to the patient's sufferings. TMien occurring
under these circumstances, it is the result of the general
venous congesriom exactly like the other serous effusions,
with which indeed it is identical. It mav seem almost im-
necessary to lay stress on this, but it has been stated by
several writers (Xiemeyer, Oppolzer) that it is the result of
engorgement of the right heart, and effusion from the coro-
nary veins and the cardiac pericardium. This is highly im-
protiable, for, in the first place, such regm-gitation is specially
provided against by the manner in which the coronary- veins
open obHquely through the wall of the right auricle, thus
acting in a valve-Hke manner ; for the greater the distension
the more the edges of the veins are closed together and
reflux prevented. Such regurgitarion of venous blood into
the heart would produce more serious consequences even
than effusion through the cardiac pericardium. The effusion
takes place from the veins of the external pericardium which
partake of the general venous engorgement in this condition
of enfeebled circularion.

4. It may occur with a general dropsical condition,
whether in acute dropsy or in the more chronic conditions of
dropsical habit, not yet understood pathologically.

5. Niemeyer is inclined to regard one form of hydroperi-

AFFECTIONS OF THE PERICARDR'M. 247

carclium as a species of compensatory effusion. He says,
" We haye already seen how a decrease in the size of the
heart, by reducing the pressure upon the pericardium from
within, results in an increase in quantity of the Hquid in the
sac. The same thing takes place when the lungs become
adherent to the pericardimn and are reduced in volume,
either from atrophy, failui-e to regain their normal size after
absorption of a plemtic effusion , or contraction from chronic
pneumonia.

" This form of hydropericardium is analogous to the iu-
crease ia the amount of cerebro- spinal fluid which takes place
in atrophy of the braia. and, as the latter is called hydroce-
phalus ex vacuo, so hydi'opericardiuni eje vacuo ^svould be a
suitable name for the former."

6. It has been found along with miliary tubercle of the
pericardium, id acute tuberculosis. Here it has no interest
other than pathological.

Symptoms. — The general or subjectiye symptoms of hy-
dropericardium are those of impeded circulation and respira-
tion. These may, howeyer, not be marked. As for the
more general symptoms these depend chiefly on the circiun-
stances with which it is associated, as in scarlatina, chronic
heart disease. v!tc.

The symptoms due to the effusion are often nil, but when
it is excessiye, as it is iu the latter stages of heart disease, it
adds to the dyspncea and forbids the horizontal posture,
compelling the patient to sit in a chair, or be propped up in
bed. No doubt the weight of the pericardial fluid in this
position falls away from the great yeiiis, and thus giyes
reUef.

The objectiye symptoms are diminished apex beat, and
somewhat of bulging of the chest wall in younger subjects,
and loss of intercostal depressions. The impulse of the
heart l^ feeble, and Walshe thinks its apex is somewhat tilted
upwards. On percussion there is increase of cardiac dulness,
increased laterally on lying down, and resembling to some
extent a triangle resting on one of its sides. But percussion
here, as usual, is apt to be interfered with by conditions of
the limg. On auscidtation the heart sounds are heard clear

248 THE HEART AND ITS DISEASES.

and distinct, but not loud ; there is no friction sound at any-
time.

Prognosis. — In scarlatina this is ordinarily good ; in chronic
kidney disease it is certainly serious ; but in chronic heart
disease it is bad indeed, and is usually a precursor, though it
can scarcely be called the cause, of death. In the other
conditions the prognosis in each case will depend much on
the peculiar circumstances of each case. In chronic lung
disease the hydropericardium ex vacuo is not likely, to say the
least of it, to pass away ; in the dropsical habit it would
entirely depend on the general condition.

Treatment. — This is by acting on the cause where practicable.
In scarlatinal dropsy the idea of Dickenson of washing out
the renal tube casts is well founded, and the achievement of
this by copious draughts of fluids is aided by the use of digi-
talis to increase the arterial tension, and increase the flow in
the glomeruli of the Malpighian bodies. Blisters may be
used over the cardiac region if necessary. In chronic kidney
disease purgatives may be resorted to when the renal secre-
tion is defective, and more so when of low specific gravity,
and these, too, brisk ones.

Potash, colchicum, buchu, and juniper may also be used
to act on the kidney, when all active congestion is past.
Hot-air baths, and other sudorifics are desirable. In chronic
heart disease digitalis may be increased in quantity, or, if not
previously used, resorted to, but it is merely as a palliative
in the great majority of instances, for any hope from treat-
ment will usually have passed away ere this stage is reached.
In other cases the treatment must be guided entirely by the
peculiarities of each case, and where a young practitioner
does not see his way, the most direct and eflective plan is to
caU in the aid of another head.

Htemopericardium. — This may occur from some injury to
the pericardium, and when so occurring, is usually absorbed,
or it may occur in rupture of the heart walls, where it is
useless to attempt remedies. It is recorded, however, that
in one case of rupture into the pericardium the patient lived
three days, and certainly clots have been found in the tears,
as if some attempt at repair was attempted.

AFFECTIONS OF THE PERICARDIUM. 249

Pneumopericardium and Pyopericardium. — These two con-
ditions are usually found combined, thougli one may precede
the other. The combined condition may arise either from
suppuration within the pericardium making its way outwards,
or from an abscess opening into the pericardium, and gas
being evolved fr'om chemical changes in the pus. It may be
in the lung and the air thus admitted with the matter. The
evidence of this accident occurring, and of air in the peri-
cardium, is the clear note, indeed tympanitic on percussion.
The tinkling of succussion is also heard. On these two wit-
nesses, in addition to what has gone on before, and the
collapse accompanying it, the diagnosis is based.

For the relief of this condition, Bamberger and Friedi-eich
recommend the use of an exploring trocar, and the subse-
quent injection of chlorine water or iodine. Nor is it easy to
see objections to this, as the already inflamed serous mem-
brane will not again put on acute inflammatory action, so
justly dreaded in a serous membrane not previously altered
by inflammation. Niemeyer relates a case of pyopericardium,
arising from cancer of the oesophagus, which occurred in his
clinic, and regards the treatment as consisting chiefly of the
administration of stimulants, which would alone be of service
in such a case.

Growths in the Pericardium. — In addition to the develop-
ment to tubercle, the pericardium is liable to become the seat
of cancer, both carcinomatous and medullary. Hydatid cysts
of the pericardium are not unknown.

250 THE HEART AND ITS DISEASES.

'^

CHAPTER XII.

Nervous Disorders of the Heart — Angina Pectoris —
Nervous Palpitation — Irritable Heart — Sub-Para-
lysis— Hyperesthesia — Graves' Disease — Chorea.

Angina Pectoris. — Angina pectoris, or "breast pang," is
also denominated neuralgia cardiaca, hyperaesthesia plexus
cardiaci, and is usually classed among the neurosal affections
of the heart; Handfield Jones and Romberg include it among
the affections of the nervous system. There is no agree-
ment among writers as to its pathology as a nervous affection.
Romberg calls it hyperaesthesia of the cardiac plexus ;
Bouillaud, a neuralgia of the phrenic nerve ; and Heberden,
cramp of the heart.* On the other hand it is admitted that
it is most commonly found in fatty degeneration of the heart,
and in ossification of the coronary arteries, the combined
condition being most frequently found along with it. Fuller
states that it is never found without structural changes to be
detected by the microscope. The best description of it is
probably a neurosal affection, occurring most commonly in
structural disease of the heart. It may somewhat elucidate
this difficult subject to see what angina pectoris is not, or
probably not ; its pathology is not a subject for bold expres-
sions or dogmatism.

An attack presents the following features, sudden on-
coming, with intense pain in the breast, extending down the
left arm, the pulse is increased in frequency most remarkably,
the heart's action is feeble, and scarcely to be detected, the
pulse is small, rapid, and almost imperceptible. In addition
the features are white, with a look of alarm on them, and
the sweat rolls down the brow in the large bead-like drops,
usually associated with intense agony, mental or bodily.
The breathing is shallow, hurried, but not laboured, the

* Anstie says it is " a mainly unilateral morbid condition of the lower cervical
and upper dorsal portion of the spinal cord."^ — " Neuralgia," 1871.

NERVOUS DISORDERS OF THE HEART. 251

patient appearing rather to not dare to breathe than to have
difficulty in doing so. The attack passes off with eructation
of wind, vomiting, or evacuation of the bowels, and commonly
a large quantity of pale-coloured urine, almost like water.
During the attack the patient preserves the same position as
occupied when seized, and dares' not be moved, the sugges-
tion to move him being pain to him and causing terror.
Here now we have some symptoms which cannot be explained
by the theories yet enunciated. The signs or objective
symptoms do not correspond with stimulation of the vagus ;
here the heart is slowed remarkably, and section of the vagus
gives irregular and tumultuous action. It is not hypergesthe-
sia of the cardiac plexus, for the heart's action is feeble and
undiscernible, and not excited ; it is not cramp, for that is
excessive ventricular contraction, if ever it occurs, and in
this condition, in digitalis poisoning, the heart has a thud, is
slow, and irregular, and there is complete, or almost complete
suppression of urine. As to its being neuralgia of the
phrenic, it is difficult to see the connection, especially with
the structural disease of the heart in which it is most fre-
quent. The pain, too, is rather a sickening, depressing
pain ; which is the character of pain, when it is received as a
sensation through the sympathetic.

There is one point on which almost all are agreed, and
that is the great lowering of the heart's action, while one point
of interest, viz., the condition of the heart after death, corro-
borates this. Von Dusch says that without doubt the aboli-
tion of the heart's action is the cause of the death resulting
from it. This effectually disposes of the theory of cramp,
and of hypersesthesia of the cardiac plexus. It is evidently
not due to an effect through the vagus, that would give the
opposite symptoms of retardation and long halts. Experi-
ments on the accelerator and depressor nerves of the heart
in animals will not account for the symptoms, though there
is great acceleration in irritation of the accelerator nerve.
It is nervous, and yet connected with structural disease of
the heart, ossified coronary arteries, and aortic atheroma. It
seems most probable that it is a disturbance of the vaso-
motor nerves within the heart. As a purely nervous affec-

252 THE HEART AND ITS DISEASES.

tion it is often connected with nterine, renal, and intestinal
affections. With these organs it is connected by the sympa-
thetic : the character of its pain shows its association with
the sympathetic. It is allied, in nature, to the arteriole
spasm of hysteria and Bright's disease, the two affections
Avitli which it is most frequently found, in the one as a purely
neurosal affection, the other as a neurosal affection intimately
associated with a structural disease.

In chronic Bright's disease, as ^ve shall see at length in
a following chapter, there is a thickening of the muscular
walls of the arterioles, a true hypertrophy of their muscular
tunic, as shown by Prof. Geo. Johnson, of King's College.

Spasm of these thickened arterioles is associated with the
cerebral anaemia so commonly found, with the dry harsh skin,
muscular pain, or when continued, wasting, and with the
white " dead " hands and feet, all common in chronic Bright's
disease.

There are stronger grounds for supposing angina pectoris
to depend on spasm of the arterioles of the heart, than are to
be found in favour of any other pathology. When too com-
plete, death results ; Avhen incomplete, an approach to it,
with a distinct sensation of its nearness. This condition is
equally reconcilable with its being reflex spasm from irrita-
tion, as when uterine at the menopause, a common period
for it in women, and passing away; or hysterical, as in younger
females; and with its frequent accompaniment of chronic
structural disease. But it may possibly arise from defective
blood supply, not being due to thickened arterioles, for in the
condition of ossification of the coronary arteries a disturbing
neurosal cause would, by producing spasm of the arterioles,
more effectually cut off the blood supply, than when the arte-
ries were sound and aiding in the arterial circulation. Limbs
perish of senile gangrene, on ossification of their nutrient
arteries, from imperfect blood supply. So in angina pectoris,
causes which would only induce an arteriole spasm in the
healthy coronary circulation so imperfect as not to constitute
angina would in disease of the coronary arteries produce more
serious effects.

Arteriole spasm would more completely arrest the blood

NERVOUS DISORDERS OF THE HEART. 253

supply in this condition than when the circulation and its
vessels were healthy. So we may safely assert that in ossifi-
cation of the coronary arteries, angina pectoris, if not more
easily induced, may be induced by alterations of the calibre
of the arterioles, which would not be so apparent in healthy
persons. That is granting that angina pectoris is the result
of spasm of the arterioles ; but this cannot be regarded as
certain — it is merely highly probable. Actual experiment of
partial ligation of the coronaries and a record of the result
and symptoms would be most interesting, and would either
corroborate or disprove this view. That angina pectoris is
due to defective blood supply from arteriole spasm seems
highly probable. In one truly neurosal case, which I had
the opportunity of frequently observing during the attack,
the later attacks terminated in an epileptiform condition, a
condition shown by Schroeder van der Kolk to be most
probably connected with variations in the calibre of the
arterioles.

Age. — It is in the more advanced periods of life that
angina pectoris is most commonly found. Forbes found 72
out of 84 cases over 50 years of age. Copland 70 cases out
of 100. It is thus associated with that time of life when
structural disease in the blood vessels is most common.

Sex. — It is most frequent in men, who are also more
commonly affected by fatty heart and atheroma. Forbes
had only 8 females in 88 cases. Heberden 3 females in 100
cases. Lartigue 7 in 67 cases, and Lussana had 97 cases a-ll
in men.

The pathological changes with which angina pectoris is
most commonly found, are thus arranged by Forbes, who in
39 cases found 24 with atheromatous degeneration of the
aorta; 16 with ossification of the coronary arteries; 16 with
calcification or other disease of the valves ; 12 with abnormal
softness of the heart.

These figures are taken from von Dusch's work.

All these figures go to prove that angina pectoris is asso-
ciated with that condition of thickening of the muscular
walls of the arterioles, with atheroma of the arteries, disease
of the valves, and fatty degeneration of the heart, all of wliicli

254 THE HEART AND ITS DISEASES.

are associated Avith chronic kidney disease, so common in
elderly men.

Diagnosis. — We have seen, in a previous chapter, in what
essentials angina pectoris differs from false angina, or cardiac
asthma, and spasmodic asthma. As seen in the aged and in
structm-al disease, it is a characteristic affection not to be
easily mistaken.

In younger persons, especially females, it is scarcely to be
distinguished from hysterical asthma, where there is shallow
breathing, hurried, small pulse, cold white skin, with rapid
and almost imperceptible pulse, and finally discharge of a large
quantity of watery pale urine. Oppolzer adds the asthma of
hypochondriasis to the asthma of hysteria as a condition from
which angina pectoris is not easily distinguished. The intense
pain is a point of distinction, but it would be difficult to pre-
vent a hysterical or hypochondriacal person adding that to
their sufferings on the slightest hint of such a thing : the
question should be put negatively in all cases of suspicion.
W. T. Gairdner has described a condition of " angina sine
dolore," where all the symptoms of angina are present, but
without the peculiar breast pain. Pain down the left arm may
occur with angina (and passes down the arm to a finger often,
or alone), and has been deemed a sort of very imperfect angina,
but its diagnostic value in heart disease is not decided upon.
In all cases of angina a most careful examination of the patient
must be made, as soon as conveniently may be, after the at-
tack, and the condition of the circulatory system keenly scru-
tinised, to determine whether the angina be simply neurosal,
or a neurosis associated with a very serious form of organic
disease. This is most important in forming a prognosis.

Prognosis and Terminations. — When simply neurosal, and,
during the intervals, the heart's action is normal, and its
sounds and impulse are good, angina is not a complaint with
a bad prognosis, serious as the attacks appear, but often
wears off, especially when occurring during the change of
life. But when associated with organic disease of the heart
and blood vessels, its import is very serious. The first attack
has been known to be fatal. In other cases the second. In
some cases the attacks recur again and again, the intervals

NERVOUS DISORDERS OF THE HEART. 255

becoming shorter, and the condition during the interval more
and more impaired, until at last one proves fatal. When the
muscular structure is the subject of molecular necrosis, its
functional power is much impaired, and the deprival of its
blood is followed by most grave abolition of function, if not
total cessation of action.

But angina pectoris is not pathognomic of fatty degene-
ration of the heart, as once thought, though it is very com-
monly associated with organic disease ; more commonly in
all probability than the figures of Forbes would seem to
indicate, if the muscular structure of the heart were in all
fatal cases subjected to accurate microscopical examination.

Treatment. — The treatment of angina pectoris consists of
two divisions : treatment during the attack, and treatment
during the interval.

When associated with fatty degeneration of the heart,
the rules laid down for that affection must be adhered to.
When simply neurosal, the treatment consists of removal of
all causational conditions as uterine congestion, or ulceration
of the OS uteri_, by their appropriate measures; ovarian irrita-
tion or congestion must be relieved; and dyspeptic and other
states attended to. Fresh air, plain food, exercise, cold
bathing, with proper moral and social management must not
be neglected. Iron, zinc, quinine, or arsenic may be given
combhied or alone. Arsenic has long held a high position as
an agent of value in the treatment of simple neurosal angina
pectoris. Its treatment is that of neuralgia, with which it is
allied. Anstie has shown (on Neuralgia) that it is one of
the manifestations of nerve disorder in families, who are
liable to these manifestations in one form, or other form, and
that it is allied to neuralgias regionally near it.

During the attack stimulants, musk, camphor, &c., have
been given. Narcotics and antispasmodics, as large doses of
opium or morphine, or even subcutaneous injections are not
very desirable agents to administer in a condition, whose
pathology is enveloped in doubt. Chloroform or other inha-
lations are not very safe agents, as their action on the heart
is not known. Mustard poultices are safe, if they are of any
service, while foot-baths, with mustard, are undesirable as

256 THE HEART AND ITS DISEASES.

tending to disturb the patient, which is never desirable
during the attack : indeed, sometimes the patient may assume
an odd attitude or position and retain it. Digitahs during
the attack has seemed to the writer to afford rehef. Cer-
tainly stimulants seemed to have more effect on the attack
after digitalis was added.

Brunton gave nitrite of amyl with good results : as
might be expected from its undoubted effect in dilating the
smaller blood-vessels.

According to Flint (p. 305), Duchenne and Aran have
found the electrisation of the skin in the precordial region
remarkably effective both in arresting the paroxysms and
postponing their occurrence.

Agents which induce ventricular contraction, or relax
arteriole spasm are indicated, and diffusible stimulants of all
kinds, from sal volatile to hot spirit and water, are indicated
and may be safely administered.

Nervous Palpitation. — Palpitation is usually classed among
the nervous affections of the heart, though it is also con-
nected with structural disease, and especially dilatation.
Palpitation has been denominated an over-action of the
heart, a condition which is not only not proven, but can
scarcely exist ; for it would simply mean obliteration of the
ventricular chamber and approximation of the walls. Then
it was denominated a derangement of nerve-balance betwixt
the branches of the vagus and the cardiac ganglia, a portion
of the sympathetic. This it may somewhat more possibly
be, though a condition of palpitation has never been attained
in any of the experiments on the ganglia and the vagus.
A condition similar, if not identical with it, has been experi-
mentally attained by Cyon, Ludwig, and von Bezold, by
irritation of the nerve centres, even when every direct nerve
communication with the heart has been severed. Contrac-
tion of the arterioles elicited quicker and more excited
action of the heart, as a simple result of the opposition
offered to the blood flow. And we know from Prof. Ruther-
ford that this is effected through the vaso-motor excitory
branch of the sympathetic, which contracts blood-vessels.*

* See 1st Cliii|)ter,

NERVOUS DISORDERS OF THE HEART. 257

Nervous palpitation is in all probability due to arteriole
spasm, offering obstruction to the flow of blood, cardiac dis-
tension from that obstruction, and palpitation its outward
sign, or objective symptom. A condition closely allied to
palpitation is found after violent exertion, before the heart
has time to settle down on the removal of the call upon it.
Violent palpitation is induced in a weak heart by any
exertion, and if it were over-action its presence would endow
the patient with the very power he lacks, viz.^ better ventri-
cular contraction ; but he is not so endowed, indeed, he is
less capable during the palpitation. Violent palpitation was
noticed by Hope when the right ventricle was almost
paralysed from over-distension, in cardiac dyspnoea. Palpi-
tation in a person quite healthy, but with a weak heart, is
induced by any sudden exertion, as running up stairs or
after an omnibus. It is obvious that palpitation is not due to
nerve disturbance when it is found in conditions so removed
from all disturbance of nerve balance. It is equally obvious
that it must belong to some condition common to all, and I
am firmly pursuaded that condition is cardiac distension,
however produced, whether by inefficiency in the muscular
walls, or by nervous action, which we now know can act
on the heart through the vaso motor nerves of the small
systemic arterioles.

We will now see how far this view is borne out by the
manifestations of a hysteric attack, where palpitation, truly
nervous, is very commonly induced. The patient is pale,
with cold hands and feet ; indeed, the skin generally is pale
and cold, the radial pulse is small and cordy, not unlike the
pulse of abdominal inflammation, the carotids are full and
bounding, and the heart feels to the hand as if it would
forcibly shatter off the anterior wall of the thorax. Along
with this there is great secretion of urine, and after the
attack a great, often enormous, quantity of pale coloured
watery urine is passed. This may be fairly taken to repre-
sent the effect of the increased arterial tension than of any
nervous action on the kidney. Now we have here evidence
in favour of arteriole spasm, the cold extremities, small radial
pulse, showing that the muscular coat of even arteries as

s

258 THE HEART AND ITS DISEASES.

large as the radial is affected, while the carotids are fall and
bonnding. The heart is struggling against a general oppo-
sition offered to it, and is in the same state as when it palpi-
tates from any other opposition offered to it ; and from
increased arterial tension, betwixt the struggling heart and
contracted arterioles, there is an increased flow of urine.
There is some positive evidence here in favour of arteriole
spasm, while the other theories have no evidence whatever
that can be adduced to corroborate them, the violent action
of the heart being no proof of anything but of demand on it,
and is induced equally in other circumstances where neither
over-action nor disturbance of nerve-balance occur. A
symptom common to different morbid states is, in all human
probability, due to a condition common to all of them. Pal-
pitation appears due to attempt upon the part of the heart
to contract and fulfil its function in the face of opposition.
Incomplete emptying leads to over-distension, and palpitation
is its objective symptom.

So when a person with a weak, and so-called excitable,
heart makes any sudden effort, as running up stairs, an
attack of palpitation is induced. This is not a disturbance
of nerve balance induced by the act of running up stairs,
but the muscular effort makes a demand on the heart, the
action of the muscles being to obstruct the blood stream,
while they tend to force on the venous blood towards the
heart ; thus temporary distension of the heart is induced, and
a temporary palpitation ensues.

Exciting Causes. — The anatomical causes of palpitation
we have just examined, but the inducing or exciting causes
of true nervous palpitation are various. First comes the
temperament. The subjects of palpitation are usually of the
nervous type, or nervous diathesis of Laycock, persons in
whom the nervous element preponderates, and who are
emotional and susceptible. Thus the nervous constitution
of the female sex renders females more liable to it than
males. Further, temporary causes affecting the emotional
nature increase this susceptibility, as sudden surprise, excite-
ment, anxiety, shock, &c. Certain periods, as the commence-
ment of the menstrual flow, and a short time before it, render

NERVOUS DISORDERS OF THE HEiRT. 259

females periodically liable to palpitation. So too at puberty
and the menopause, and also after indulgence in stimulants
and too much tea, in males tobacco, it is found : here there
is exhaustion of the sympathetic, and cardiac inability, so
that distension is more easily induced. The effect of ovarian
excitement, of too frequent indulgence in coitus, or in sub-
stitutes for it, is marked; indeed, palpitation is commonly
associated with hysteria, whose pathology — if it really has
one, and it is probable — is shown by Dr. Matthews Duncan
to be due to ovarian congestion or chronic ovaritis.

Palpitation is connected with disturbances of the sympa-
thetic by disease of any viscus, especially pelvic, and by
exhaustion of the sympathetic, however induced.

Palpitation may arise in a weak heart from sudden effort,
from any call upon the heart, and of course true nervous pal-
pitation will more readily be produced in those persons than
others, so that its production in them by effort at one time,
and by mental emotion at another, is quite reconcilable, and
is easily comprehended. It is common in the subjects of
Bright's disease, for reasons we shall see after, and the
changes in the arteriole walls induced by this disease would
also render them liable to true nervous palpitation.

Age. — Youth is more subject to palpitation than adult
life. It rarely occurs before puberty, except from sudden
start, or shock. It occurs in adults in middle life, in women
chiefly, and in some nervous men ; and in advanced life,
when heart disease and Bright's disease are more frequent,
it is again found more commonly.

Se^. — Women are more decidedly liable to palpitation
than men. This is due to their more susceptible nervous
system, their emotional and impressible nature. That arte-
riole neurosal changes of calibre are more readily induced in
women than men is evidenced by the blush, that strange
momentary dilatation of the arterioles, not of the face only,
but, as Romberg shows, it extends over the genitals and
thighs. The more the nervous system in men apx>roache8
the feminine type, the more liable is the owner to palpitation,
while some men's nervous systems seem as if such disturb-
ance were almost impossible.

s 2

260 THE HEART AND ITS DISEASES.

Prognosis. — Tlie prognosis of palpitation itself is not
serious, but it may indicate a grave condition. But palpita-
tion of a violent character, sucli as obtrudes itself forcibly
on the patient's attention, is more decidedly the charac-
teristic of nervous disorders of the heart than structural
lesions. In people feeling ^well ordinarily, violent palpitation
is much more probably due to arteriole spasm than cardiac
debility. Palpitation is not so especially a characteristic of
organic disease, and when it then occurs is rarely so violent,
and is induced by effort rather than by emotion. It is easily
induced in cardiac dilatation, and is then persistent, that is,
it is not more easily induced by effort at one time than
another. Some elderly people rather like to show to their
medical attendant how easily palpitation is induced by a few
quick steps across the floor. But this is not nervous palpi-
tation, and must not be so considered ; it is palpitation other-
wise induced. In advanced disease of the heart, palpitation
is almost a good symptom, as showing that the heart can
still palpitate ; and in chronic irregularity, palpitation on
effort is not nearly so serious a matter as when intermittency
or syncope is so induced.

True nervous palpitation may indicate nervous exhaus-
tion ; and its recurrence at shorter intervals, or in greater
force, and for more prolonged periods, is not a symptom to
be overlooked. It may indicate mental strain of a nervous
system tried from its psychical and not its physical side. It
may indicate in celibate females that the nervous system is
beginning to suffer from an enforced involuntary continence.
Its prognostic import is not so much with itself as with the
condition to which it belongs, or in which it takes its origin.
Peter Frank is a well-known case of palpitation induced by
arduous study of heart disease, and the action of the heart
may be increased in rapidity or in force by voluntary atten-
tion to it. Where nervous palpitation alarms the patient, it
is more likely to pei-petuate itself

Treatment, — The treatment of nervous palpitation, like
that of angina pectoris, has two divisions — tlie treatment of
the paroxysm, and the general treatment during the inter-
vals. The treatment of the attack consists of placing tlie

NERVOUS DISORDERS OF THE HEART. 261

patient on a conch, or in bed, avoidance of all appearance
of alarm, and a suppression of exuberant sympatliy, with
the use of eau de Cologne or sal-volatile. It is questionable
how far musk or other animal scents act on the emotional
nature through the sense of smell, as Laycock suggests,
though it is difficult to see any other physical action, but
probably they act by diverting the attention. If connected
with a hysteric paroxysm, C. J. Hare's suggestion of holding
the nose till a deep inspiration is induced, may be put in
practice. The action of a deep inspiration is inexplicable,
but its efficacy is wonderful in arresting a hysteric paroxysm.
When palpitation is induced by sudden effi)rt, rest, quiet, and
a diffusible stimulant are indicated, with a few drops of tinc-
ture of belladonna or digitalis.

The treatment of nervous palpitation during the interval
is a somewhat difficult subject. It means the treatment of
the condition on which it depends, and that is a wide subject.
A brief bird's eye view is all that is admissible here. Where
it is due to a finely strung and susceptible nervous tempera-
ment, of course no treatment can affect that ; but quiet,
mental or bodily, avoidance of all exciting pursuits, which
would tend to make the system more hyper aesthetic, are
indicated, while any trivial visceral disturbance must be
attended to at once, for a system of that kind will not right
itself without suffering. Where it is associated with in-door
occupations, fresh air and exercise are imperatively dictated.
Cold water sponging or baths are ever of service. The
excitement of modern fiction is not without an effect on the
emotional nature of its votaries, who become as abandoned
to this form of intemperance as others are to the use or
abuse of other stimulants. The enthralling plot, which the
victim to novel reading demands, is allied to the demand for
brandy in the toper ; slighter stimulants are inefficient and
powerless. This excitement, occasioned by plot or story,
affects the emotional nature, so closely allied to the sympa-
thetic or ganglionic system, by increasing its susceptibility.
Here removal from a circulatmg library is a necessary step,
and exercise, other occupations, and rational mental pabulum,
the interest attracted in some other direction, are necessary.

262 THE HEART AND ITS DISEASES.

More hopeless still is the case where the mental activity
takes a theological, or so-called religious, direction. Here a
conviction of higher duties than those connected with the
natural man presents an almost insuperable barrier to the
adoption of medical advice. The conventual seclusion of the
Romish Church had at least one good, in the prevention of
another generation of beings with this highly developed
emotional nature so destructive of their own comfort. The
progress of civilisation, and its effect in heightening the
susceptibility of the nervous system, both cerebral and
ganglionic, bears heavily on our unmarried or single sisters.
The impulses or promptings of the afifectional nature become,
as Maudsley well has shown, stimulated by a life of con-
strained celibacy, and the denial of their gratification adds
to their pertinacity till they become dominant ; this reacts
upon the circulation within the ovaries, and persistent
ovarian congestion converts these promptings into almost
omnipresence, and these occasional longings become de-
veloped into physiological necessities. Homo sum! et nihil
liumani a me alienum j^uto ! And the life which is before many
of the weaker sex cannot but tend to induce them to be frail.
We can find charity for soldiers, where their military regula-
tions do not permit matrimony. Can we not be at least as
charitable to those of the female sex, who are quite as
stringently compelled to be continent, with even less to
occupy their attention ? With matrimony as almost the sole
future presented to her hopes, a spinster's thoughts are
necessarily diverted in an erotic direction; nor can we
wonder if that affects her susceptible nervous system. Many
cases of nervous palpitation, as well as hysteric attacks, are
improved, and even cured, when the. cares of maternity are
added to the caresses of a husband, and the emotions get
settled down into healtliy channels when the aspirations
have attained their gratification. " The treatment of hysteria
does not consist in the administration of nauseous gums,
but in proper mental, social, and moral management." —
(Russell Reynolds, in " System of Medicine.")

The medical treatment consists of cold-water baths, the
use of the bidet, the unloading of all pelvic congestion, and

NERVOUS DISORDERS OF THE HEART. 263

especial attention should be paid to the condition of the
rectum, too apt to be neglected. When the nervous system
is more than ordinarily excited, camphor and bromide of
potassium are indicated. Disturbed rest is better met by
early rising, active exercise, and light suppers, than by
opiates or other narcotics, or even by morning slumber.
While in those common cases of anaemia and chlorosis arsenic
and iron, quinine or strychnine, with cod-liver oil, and a
nutritious diet, are of service ; the combination of haematics
with nervine tonics is of great importance. All discharges
of every kind must be checked as far as possible, as being
drains on the system. Belladonna plaisters may be worn
with advantage.

Where palpitation is connected with sudden efforts and
a weak heart, it is less likely to affect the heart through the
sympathetic branches, tliough this view has the authority of
Ludv^ig, but through the sudden demand on the muscular
walls. Here digitalis is of great service, or belladonna, where
palpitation is both emotional and from exertion. Avoidance
of sudden effort is deshable, and tonics may be indicated.
But any temporary measures, though they may give relief
for a time_, are ineffective as to the general condition, and
recurring periods of treatment may not only be necessary,
but even desirable.

When palpitation occurs in chronic Bright's disease, it
must be treated by the rules to be laid down in the chapter
devoted to the combination of heart and kidney disease.

Irritable Heart, — This subject has been especially investi-
gated by Da Costa, of Philadelphia, whose attention was
drawn forcibly to it during the American Civil War. By his
kindness in sending his papers to the writer, a complete, but
abridged view of this affection can be laid before the reader
in the language of Da Costa himself : —

" The general clinical history of many of the cases was
this : — A man, who had been for some months or longer in
active service, would be seized with diarrhoea, annoying, but
not severe enough to keep him out of the field ; or, attacked
with diarrhoea or fever, he re-joined, after a short stay in
hospital, his command, and again underwent the fatigues of

264 THE HEART AND ITS DISEASES.

a soldier's life. He soon noticed that he could not bear them
as formerly ; he got out of breath, could not keep up with
his comrades, was annoyed with dizziness and palpitation,
and with pain in the chest ; his accoutrements oppressed him,
and all this though he appeared well and healthy. Seeking
advice from the surgeon of the regiment it was decided that
he was unfit for duty, and he was sent to a hospital, where
his persistently quick-acting heart confirmed his story,
though he looked like a man in sound condition.

" Any digestive disturbances which might have existed
gradually passed away, but the irregularity in the heart re-
mained, and only very slowly did the excited organ return
to its natural condition. Or it failed to do so, notwithstand-
ing the use of remedies which control the cnculation ; thus
the case might go on for a long time, and the patient, after
being the round of the hospitals, would be discharged, or, as
imfit for active duty, placed in the Invalid Corps."

This account clearly indicates that though the provoking
cause of the affection is exhaustion of the sympathetic, still
there is also a condition allied hi nature to Graves's or Base-
dow's disease, and as intractable to remedies. Some cases
seem to have been almost entirely due to exhaustion of the
sympathetic, and these readily yielded to treatment and rest,
while the others, which partook of the neurosal character of
Basedow's disease, were scarcely, if at all, benefited by
treatment.

The tendency of the cases was to develop hypertrophy,
and in some cases this became marked, but in the majority it
was trifling in amount. In one case, a fairly typical one,
death from strangulated hernia furnished an opportunity of
examining the heart. " The pericardium was healthy ; the
heart, before being opened, appeared to be of normal size ; at
its upper portion was a moderate amount of fat ; the valves
were all healthy ; a small clot was entwined in the mitral
valve ; the auricles were of normal size, and so were the
cavities of the ventricles ; the muscular structure of these
was firm, and the cut surface glistening. While, as already
stated, the cavity of the left ventricle did not appear in-
creased, there was a great disproportion between its walls

NERVOUS DISORDERS OF THE HEART. 265

and those of the right side ; these measured less than one-
fonrth of an inch at some parts, a fraction over one-fourth at
the thickest portion ; whereas the walls of the left ventricle
were nearly seven-eighths of an inch at the thickest part, and
varied from a little over one-half to three-fourths of an inch
at others. Microscopically examined, the fibres were healthy,
some fibres seemed indistinct, but there was neither fatty nor
granular degeneration. The nervous filaments of the heart,
as far as they were traced out, appeared healthy, but no
minute dissection of the heart was made." The physical
signs in life were ''impulse somewhat extended, but not
decidedly abrupt, and of some force ; the second sound is
very distinct."

Causes. — " In no part of this inquiry is it more difficult to
arrive at fixed conclusions, for manv causes seem at times to
have been combined, and it is scarcely possible, even by the
most vigorous analysis, to fix specially upon one." Of 200
selected and well-marked cases, the analysis stands thus :■ —

Fevers 34 17 per cent.

Diarrlioea 61 305 „

Hard field service, particularly excessive marching . 69 38*5 „
Wounds, injuries, rheumatism, scurvy, ordinary "1

duties of soldier life, and doubtful causes .... J "

200 100*

We see from this that hard field service was a large factor in
the production of these cases, and nextly diarrhoea, and
thirdly fevers. These are depressant causes, and no doubt
led largely in the immediate provocation of the malady, but
one great factor in the production of this ailment, which is
so intimately connected with the ganglionic or emotional
nature, is the excitement, and, to some extent, natural
anxiety of this war, which manifested a most unusual dead-
liness. There was much wilful and unnecessary bloodshed,
as remarked by military critics, and this, together with the
high nervous development of Americans^ the social character
of the struggle, the obstinate nature of the fighting, as soon
as any troops were seasoned, the novel character of many of

* 104 (?).

2Q6 THE HEART AND ITS DISEASES.

the militaiy evolutions, all go to make up a total which ex-
plains the occurrence of this type of disease in the American
war, and to account for its fi^equency there. The struggle,
too, was prolonged over some years, with varying success,
which separates this from the wars of 1864, 1866, and 1870-1
in Europe.

Tobacco in its various forms does not appear to have
been a producing cause, " some of the worst cases occurring
in those who did not use it in any shape." Nor did sexual
excess, or the substitutes for it, ^' pi'oduce the disorder,
though they predisposed to it, or kept it up." " We find it
most readily developed in those previously weak and unac-
customed to fatigue, or subject to readily-quickened circula-
tion. We find it kept up by irksome equipments and other
causes, but not generated by them. (Many cases occurred
in cavalry and artillery as well as infantry.) In all those
cases it was apt to be noticed that, from the onset, the
double quick was badly borne."

Symptoms. Palpitation. — This differed in individual cases
both in severity and frequency, and considerably, too. Pal-
pitation was usually accompanied by pain over the heart and
in the left shoulder ; there was often a great deal of distress ;
the attacks came on variously, often excited by exertion, but
at other times coming on at night in bed. As a rule, the
patient could not lie on his left side for fear of exciting them.
Pain was an almost constant symptom. The chief seat of
the pain was the lower part of the precordia, particularly
near the apex. There was also hyper^esthesia. The pain was
not due to intercostal neuralgia. Pulse. This was generally
rapid, varying from 100 to 140. In character it was small,
and easily compressible. The pulse was always greatly and
rapidly influenced by position, varying from 108 when
standing, to 80 when lying down, or in another case from
120 to 84. Respiration was emban-assed, and shortness of
breath complained of, yet, notwithstanding all the signs of
dyspnoea, it was astonishing that the respiration was so little
hurried, as for instance, pulse 124, respirations 25 ; pulse 146,
respirations 26. Nervous symptoms were complained of,
especially headache, giddiness, and disturbed sleep. The

NERVOUS DISORDERS OF THE HEART. 267

sleep was disturbed by jerking, or by unpleasant dreams.
Digestive disorders were frequent.

Inordinate sweating of the hand was several times com-
plained of, and Da Costa thinks this was due to disorder of
the sympathic, and a modification of the general excessive
perspiration.

Physical Signs. Impulse, — " This was almost always ex-
tended, yet not correspondingly forcible ; rather it is abrupt
or jerky, and quick." There is commonly some hypertrophy
with its characteristic signs, but rarely dilatation. Murmurs,
obscuring or replacing the cardiac sounds are not, as a rule,
present : when occurring, they are usually systolic and heard
at the apex, thus differing from the aortic murmur of
anaemia.

Diagnosis. — This is usually not very difficult, and is
founded on an aggregation of the signs and symptoms, given
above, along with the history. The irritable heart differs from
dilatation in the absence of extended dulness and subjective
symptoms. It appears that it may most readily be mistaken
for phthisis, unliliely as it appears at first sight. There is
irritative cough, with expectoration, and often haemoptysis,
especially after exertion. '' But the aspect of the patient,
the pain in the precordial region, the attacks of palpitation,
and absence of the physical signs of tubercle, furnish the dis-
tinctive traits."

It is sometimes feigned by tying a tight bandage round
the lower part of the chest and upper part of the abdomen.
The suspected patient must be stripped and told to lie down,
when the rapidity of pulse falls, but does not mount again on
his resuming the erect posture. The impostor often overlooks
the characteristic cardiac pain.

Prognosis and Treatment, — The prognosis varies much
apparently with the malady itself. When indicating rather
exhaustion of the sympathetic by hard marching and pro-
longed excitement, it seems fairly amenable to treatment,
especially when combined with rest.

But in other cases, which seem rather allied to Basedow's
disease, and to indicate a neurosis rather than any simple
exhaustion of the sympathetic, the case is decidedly dif-

268 THE HEART AND ITS DISEASES.

ferent, and the prognosis resembles that of Basedow's
disease.

Da Costa says, speaking generally, " The treatment is
never a short one ; and the question arises, would it not be
better for the Government at once to discharge these heart
cases ? " In answer, he thinks it not desirable, as leading to
encourage heart affections (functional) among soldiers in war
times, and prefers placing these patients in the veteran reserve,
or to do mere routine duties, not entailing fatigue and ex-
citement, to their unconditional discharge, which, he thinks,
would have a " demoralising effect." Having decided upon
retaining them in the service, the next question very
naturally is that of treatment. The first point to be attended
to is rest, ever of so much importance in the treatment of
heart affections. The great difficulty is simply to get rest in
these cases, where it is almost out of question from the
nature of things. When practicable, it is of the highest
importance. Nextly, as to remedies. Digitalis and its active
principle digitaline were employed ; there was no difference
in their utility, " and both had more influence on the cardiac
disorder than any other drug which was resorted to." Then
came veratrium viride and belladonna, both of which were
useful. Belladonna seemed to exercise great control over
the element of irregularity, and often advantageously pre-
ceded the administration of digitalis and iron. This com-
bination was most useful in cases of debility, combined with
greatly increased rapidity of pulse. In other cases, aconite
seemed more desh-able. " On purely irritable hearts it had
very little effect, nay, repeatedly it was noticed that the im-
pulse became more frequent under its use, and even more
abrupt."

" But it was, after all, in cases of decided increase in the
organ, in cases of hypertrophy, that aconite most showed its
influence, he goes on to say, after mentioning its influence in
apparently arresting organic changes. As to opium, it ap-
peared to exercise some quieting action on the heart, but is
not likely to be of much service ordinarily, so far as its exhi-
bition for concurrent affections, as dysentery, would warrant
conclusions. Hypodermic injections of morphia were often

NERVOUS DISORDERS OF THE HEART. 2(59

resorted to for the relief of the cardiac pain, and almost in-
variably, at least for the time being, accomplished the desired
object."

Strychnine, quinine, iron, and zinc were all serviceable in
their place, and especially after the active irritability had
been allayed. " Great care was taken with the men dm-ing
convalescence. They were mostly placed on guard duty, or
other light duty, some still continuing treatment in a modified
degree, others not ; and were ordered up for examination at
stated intervals." Finally, it may be remarked that the
treatment appears to the writer to have been conducted on
two principles, during the first part of the treatment, viz., to
give either agents increasing vaso-motor action and arterial
tension, or agents lowering both. That in certain cases
digitalis, belladonna, veratrium viride, or strychnine were
most beneficial, and that in these cases there was debility
and low arterial tension. In other cases with forcible action
and tendency to hypertrophy, aconite was more useful.
There was an evident antagonism existing, and cases bene-
fited by one plan, usually, were aggravated by the other.
In the first series of cases an agent which increased the tone
of the cardiac contractions, while acting also on the peripheral
muscular portion of the circulatory system, was indicated, in
the others an agent which lowered arterial tension, acting on
heart and arterioles by lessening their contractibility, was
rather of service.

The inseparability of action on the central and peripheral
portions of the circulation, ix.^ of exciting increased contrac-
tility in the central muscular mass, the heart, without a
similar action on the peripheral muscular distribution, and
vice versa, explains why good effects should have been
attained from agents so antagonistic as digitalis and aconite ;
though, it must be borne in mind, not in the same cases.

The functional affection of '^ initable heart " as described
by Da Costa is quite dissevered from those diseases of the
heart in soldiers described by Dr. Myers in his Alexandra
Prize Essay, Avhich apparently arise alike in peace and war ;
and, though unquestionably connected with exertion, are
specially due to the tight jackets and padded waistcoats

270 THE HEART AND ITS DISEASES.

which seem deemed indispensable to the British soldier, and
by which his health, as well as his comfort, is sacrificed
to some peculiar aesthetic views as to the ideal physique of a
soldier.

Sub-Paralysis of the Heart. — This is an affection in many
respects allied to nervous palpitation, including a muscular
counterfeit. It is characterised by a feeble, compressible
pulse, not unnaturally fast, it may even be slow, with a
tendency to irregularity, or to intermit. The heart's action
is in accordance with this ; the sounds are low, and the
impulse feeble. At other times there is great rapidity and
feebleness in the pulse, as seen in some cases of delirium
tremens, when the delirium is due to anaemia, and the cases
yield rapidly to the digitalis.

Sub-paralysis of the heart is an affection which needs
more attention being paid to it, and needs clearing up.
There seems three conditions under which it occurs, namely,
exhaustion of the sympathetic, affections of the vagus, and
muscular exhaustion.

Exhaustion of the sympathetic is the most common of all
causes, and is variously induced. Excessive tobacco smoking,
though borne by some with impunity, is very injurious to
others, and it is well known that many men can smoke light
tobacco with impunity, who are soon compelled to give up
strong tobacco. The pulse is readily affected by strong
tobacco, and is then quick, feeble, and tending to be irregular-
Exhaustion from excessive stimulants, and from excessive
strain on the nerve force, and consequent imperfect supply
of the sympathetic nerve centres which preside over visceral
involuntary actions, including the heart, is injurious, how-
ever produced. The defective action of the heart imperfectly
supplies the cerebro spinal centres with blood, less nerve
force is evolved, and the sympathetic is imperfectly supplied,
and the condition perpetuated. This drain may be variously
induced, and one case which came under my notice in Vienna
is instructive. The gentleman possessed a physique of more
than ordinary vigour, and the muscular or acting force was
good, and also the vital forces under e'xertion. But it so
happened that he was also given to sexual indulgence, and

NERVOUS DISORDERS OF THE HEART. 271

this affected his pulsations markedly. The heart's action
was feeble and the pulse small, normally fast, and very com-
pressible. This was more marked after indulgence, but
became somewhat chronic. Once previously, under similar
circumstances, the same state had been induced. At last,
getting uneasy about it, he went off for a walking tour,
somewhat doubtful about his power to sustain exertion. But,
to his astonishment, he soon got a good pulse, was more
equal even to exertion, mountain climbing gave no incon-
venience, every symptom of cardiac debility passed away,
until, during his Viennese residence, the old habits were re-
sumed, and with them came back the old feeble condition of
heart and pulse, with exacerbations too markedly connected
with his mdiscretions to leave any doubt about their standing
to each other in the relation of cause and effect.

The condition of sub-paralysis of the heart from exhaus-
tion of the ganghonic system is a subject of more interest
than it has excited, and the imperfect contraction of the
heart, due to this ganglionic failure, is of interest, practically,
as well as bearing on the subject of cardiac innervation.

Sub-paralysis of the heart is an affection which must not be
connected with abnormal slowness of the pulse. Some per-
sons have an abnormally slow pulse, without any disease or
inability. One case was reported to me in Berlin, where a
gentleman had been rejected for military service on this ac-
count, though quite healthy and well. His pulse is ordinarily
40, and when ill may mount up to 80, showing an increase
in number of beats quite normal enough, and demonstrating
that there is no disorder, but merely what, in lieu of more
knowledge, we must denominate a peculiarity. Cases of
abnormal slowness occurring in sickness are not unknown,
and in one whole family in the north of England this occurs.
The pulse falls to 35 or 40 during illness, but this does not
appear a source of danger, and the condition during health
is that of robustness, and the life of average duration.

Sub-paralysis cordis may be produced by causes acting
through the inhibitory action of the vagus, and one noted
case, where this was diagnosed during life, is worth relating.
It occurred in the Krankenhaus of Vienna, and was seen by

272 THE HEART AND ITS DISEASES.

Heine and Skoda. The heart stood still for five or six beats.
During this time the patient's appearance " told that some-
thing terrible was going on within him ; " he suffered mental
as well as bodily agony. He ultimately lost the power of
speech, and had paralysis of all his extremities. The diag-
nosis was tumour of the vagus, with hypertrophy of the
cervical portion of the spinal cord. Skoda's diagnosis was
almost unerring, when he ventured one ; and Rokitansky
found the lesions diagnosed, the tumour in the vagus being
about the size of a cherry, and embracing the nerve. This
case is almost unique, and Romberg, in his work on the
Diseases of the Nervous System, does not give another
(vol. ii, p. 340).

Arrest of the heart's action by will through the vagi is
a common practice with Indian jugglers, and one Indian
officer acquired the art, and ultimately fell a victim to a pro-
longed effort, from which he never recovered. In shock, or
syncope from mental emotion, it is perhaps not easy to say
how far impressions from the brain act through the vagi in
producing cardiac syncope, but it is not probable that this is
the usual causation. Shock is described by Romberg as a
"paralysis of the sympathetic," and it is often associated
with causes Avhich remove it from influence through the
vagi. Collapse is a similar arrest of action, acting through
the sympathetic rather than the vagus.

Muscular Suh-Paralysis. — This affection was described by
earlier writers as acute distension or engorgement of the
lieart, that is, a condition of ventricular fulness to the verge
of paralysis. That, in diseased hearts, this may proceed to
final cessation in diastole, is well knoAvn as a common cause
of sudden death, but it is a not uncommon condition in
healthy hearts. It is especially liable to occur in the right
ventricle on effort, for when effort is proti'acted as well as
laborious, the impeded circulation, due to the accumulation
of non-oxygenised blood in the lungs, and the distension of
the right side of the heart, possibly aided by the presence of so
large a quantity of blood charged with carbonic acid, neces-
sitate cessation of all effort from dyspnoea, and a distressing
sense of distention and pulsation in the heart. Cessation of

NERVOUS DISORDERS OF THE HEART. 273

effort gives relief, but the resumption of effort reprovokes
the unpleasant symptoms. They are apt to return, or even
to persist in a chronic form of cardiac asthma. Dr. Clifford
Allbutt has given a description, with his usual felicity, of an
attack which occurred to himself."^ After a long day's
Alpine walking, a further ascent was attempted. This new
effort produced suddenly " a strange and peculiar hesoin de
respirer, accompanied by a very distressing sense of disten-
sion, and pulsation in the epigastrium. Od placing my hand
over my heart, I felt a labouring diffused beat all over the
epigastrium," he goes on to say. Rest gave relief; but
climbmg brought it back. After reaching level ground all
was well ; but at about three in the morning he was
awakened suddenly with a return of the attack. Dr. Allbutt
may be congratulated that that morning attack was the last
he knew of his over-distension of the right ventricle, as
several cases of its remaining for a considerable time have
come under my notice. The prolonged strain, or frequently
repeated strain, on the right ventricle produces partial
paralysis and loss of resisting power. Thus swimmers and
divers find that they can "train off" as well as "train on."
To '■ tram on " means improveraent in wind, and to " train
off," the opposite. The right ventricle is then overstrained,
and becomes less equal to demand on it. In the diving
mammals the right ventricle is comparatively much stronger
than in other mammals, and supported by trabeculse, of
which the column se carnese are the homologues-t In two
very marked cases of cardiac asthma in healthy young men,
this prolonged effort, after nature's admonitions to desist have
been disregarded by " pluck," was the cause in both — in one
after prolonged gymnastic feats in a competition, where
hei'nia resulted at the same time from the efforts made, and
in the other, running long after marked uncomfortable feel-
ings were present, but disregarded in favour of other even
more strongly impelling motives. The same thing occurs in

* " The Effect of Overwork and Strain on the Heart and Great Blood-
vessels." 1871.

t To those interested in this subject, the writer can refer them a paper by
him in the " Edin. Monthly Med. Journ.," Dec, 1870, under the somewhat
clumsy title of " Cardiac Distensibility, Distension, and Dilatation."

T

274 THE HEART AND ITS DISEASES.

horses that are broken-winded from a hard ride or hunt, and
a winter or summer out at grass is a common cure. It is not
to be supposed that there is any curative property about
grass, as compared to its dried condition, hay ; it is the rest
from exertion, except such as is vohmtary and can be
desisted from at the horse's will, and not his rider's, that per-
mits of recovery. The horse usually drops, as does the
soldier out of the ranks, when " on the march," from cerebral
anaemia due to this condition, or rather to deprival of
arterial blood. The distension of the right ventricle, and
the general venous congestion, connected with prolonged
muscular effort, as we have seen in a previous chapter,
lead to active venous congestion within the encephalon,
while the right ventricle, transmitting only a small quantity
of blood over to the left ventricle through the gorged
lungs, there is only a small amount of oxygenised arterial
blood sent to the brain, and the brain falters for want of
its arterial blood just as we have seen it does in chronic
heart disease.

A curious account of the effect of strain, of over-exertion,
was related to me by my friend Dr. Brunson, of New York,
in Vienna. When doing a pedestrian tour in the Tyrol, after
a long and arduous ascent of the most perilous character, he
felt his head swim when on a giddy height ; being a man of
iron nerves, he kept complete command over himself during
the perilous feats requisite ere he could again descend from
the peak. On discussing the subject with his guides, which
his command of the language enabled him to 'do freely, he
found that a total loss of self-command and of nerve was not
by any means uncommon on the peaks and glaciers, and the
victim had often to be literally borne down as best might be
by the guides. These guides had also observed that severe
and long-sustahied efforts had usually preceded these
attacks, or the sufferers liad been previously out of sorts, or
not in good condition. Here there can exist no doubt tliat
there was cerebral anaemia from an exhausted and imper-
fectly-contracting heart, due to a condition of general ex-
haustion of the sympatlietic. Many of the sufferers had
done many ascents and feats of climbing previously with-

NERVOUS DISORDERS OF THE HEART. 275

out any such feeling. Interesting as would have been the
account of Dr. Allbutt's experience had his attack seized
him on a peak or pass, and to be regretted for the sake of
science, as it will not often happen that so capable an ob-
server is in such a physicaJ condition among the Alps, and
even more interesting if there were also this cerebral anaemia
(though I am afraid he is too cool to have exhibited this
phenomenon very markedly), it is possible the experience
would not have been pleasant personally, however scientifi-
cally interesting.

This condition of over-distension of the right ventricle
is quite common in chronic disease of the heart, and also m
the curious attacks of dyspnoea in chronic Bright's disease,
where spasm of the pulmonary arterioles, excited by the
impure blood, is the probable cause of the right-side failure,
venous congestion, cyanosis, and small arterial pulse con-
nected with this condition. Dr. Peacock, in his Croonian
Lectures, 1865, thinks that the impure air of the mines has
something to do with the dilatation of the heart in Cornish
miners, as well as the exertion required, and with this opinion
I quite agree, as the imperfect oxygenation and highly
venous condition of blood must affect the right ventricle and
tend to paralyse it ; as we know that Cyon produced paraly-
sis of the heart from serum charged with carbonic acid, and
that the contractions returned when the carbonic acid was
shut off, and ceased on its being again added (Sydenham
Society's Year Book, 1867-68). This sub-paralysis of the
right ventricle may become something more, and is a not
unusual cause of death in acute zymotic disease and affec-
tions of the respiratory organs. Here the pulse mounts
higher and higher, becomes irregular, then more irregular
and intermits, and then finally ceases in diastole, and on the
'post mortem the right ventricle is found gorged with blood,
while the left ventricle is empty and contracted. It is
obvious here that the mounting and hregularity were con-
nected with the right ventricle, and not the left, for the left
had no obstacle to encounter, but must keep time with the
right in consequence of the fibres common to both, and so

T 2

276 THE HEART AND ITS DISEASES.

transmit to the arterial system the character of the contrac-
tions of the right ventricle.

Treatment. — This depends upon the nature of the com-
plaint with which this sub-paralysis is associated, on which
the diagnosis and prognosis also depend, for in some cases it
is only a neurosal or otherwise passing affection, in others a
grave chronic condition, and in others again the precursor of
death. Removal of the exciting causes, where practicable,
is, of course, demanded, with the administration of stimu-
lants and perfect quiet insisted on for a time, in the acute
attacks ; while in the more chronic conditions of exhaustion
of the sympathetic good food and altered habits are desirable ;
and in muscular debihty of the heart walls digitalis or bella-
donna, with iron, quinine, or strychnine, are indicated. In
cases, like Heine's, of tumour of the vagus, nothing curative
can be done, and palliative treatment is all that is feasible,
though it is not likely such an extremely clever diagnosis can
often be made. In those cases of acute over-distension con-
nected with muscular exertion, care for the future for those
who have suffered, and advice to those who may suffer, as to
avoidance of prolonged exertion, especially when not in
good condition, are available ; while the more persistent
chronic condition is to be met by agents which induce more
perfect ventricular contraction, and avoidance of aggravation
by new efforts is to be recommended.

Basedow s or Graves Disease. Exoplithalmic Goitre. — This
affection has had great attention paid to it by numerous
intellects of the highest order, and is connected with the
names of Basedow, Graves, Stokes, Begbie, Aran, Trousseau,
Charcot, Remak, von Graefe, Oppolzer, Traube, Virchow,
and von Recklinghausen, &c. It still remains, however,
without any positive pathology, and its aetiology is yet
shrouded in mystery. Its prominent points consist of a
curious union of three apparently totally separate affections,
viz., heart disturbance, enlargement of the thyroid gland,
and unusual fulness or prominence of the eyeballs. To these
may be added a decidedly emotional temperament. It may
be well to consider each division in turn in relation to the

NERVOUS DISORDERS OF THE HEART. 277

changes observed in tliem, as the phrase " tlie pathological
anatomy " is scarcely quite applicable.

The Heart. — The symptoms associated with the heart are
decided tumultnons action, extreme rapidity of pulse,
amounting to 160 or even 200 beats per minute, while the
heart seems thrown bodily against the thoracic parietes at
each systole, and the impulse is diffused over a large area.
There is usually some enlargement of the heart, and in-
creased dulness, and the heart much resembles in every
respect a dilated and hypertrophied heart under excitement.
There may also be valvular disease, but it is not character-
istic ; a systolic murmur may be heard at the apex, and a
thrill be felt, but this is liable to occur from disordered action
of the musculi papillares. As well as the excited action
about the heart, there is also abdominal pulsation, and the
carotids are full, and give a thrill. The radial pulse is usually
small, and not in proportion to the heart's action.

The Thyroid. — The thyroid gland is enlarged, may vary
in bulk, and has not the firm feel of bronchocele, but
rather an elastic feel, and pulsates. This is due to a dilated
condition of the branches of the thyroid artery. Under ex-
citement, the thyroid is enlarged even more and the sensation
of pulsation is increased. There may be a thrill or even a
murmui', and the right lobe is sometimes larger than the
left.

The Eyes. — The expression of the eye varies, and when it
is only slightly prominent, it appears little more than a full,
large eye, giving an interesting expression to the features.
When the eyeball is more prominent, it gives a wild, scared
look to the person, somewhat resembling the look of a hunted
animal. In some cases the eyelids are unable to close over
the eye, and this is seen in sleep markedly, the cornea is
then imperfectly covered, and this, together with the tension,
leads to various changes in the cornea. Thus, soon it be-
comes catarrhal, or ulcerates, or becomes infiltrated with pus.
The upper eyelid is swollen with blue veins in it. Von
Graefe regarded a retraction of the upper eyelid with a
downward cast of the eye itself as pathognomonic of this
affection. The pupil is normal, and the ophthalmoscopic signs

278 THE HEART AND ITS DISEASES.

negative. There is sometimes nem-algia of the ophthalmic
branch of the fifth nerve.

The Temperament. — The temperament is emotional, sus-
ceptible, and sensitive. This leads to mental disturbances,
and the patient is easily distressed, apt to attach more
importance to httle matters than they really deserve, and, if
a married woman, is liable to frequently make quarrels with
her husband. When in Leeds Public Dispensary, the writer
always asked if they felt often inclined to quarrel with, or
scold their husband, and after a crimson blush an affirmative
answer was always given. This inclination to have httle
quarrels and arguments was uncontrollable, and to some
extent involuntary. The patients are usually of a somewhat
refined temperament, and these mental ebullitions distressed
them much after. There is a great approach to the hysterical
temperament in these patients. The very fact of having a
greater inclination to be angry with their husbands showed
the emotional character of the affection, and in all probability
the real cause was some imagined indifference, or trifling
neglect, brooded over and magnified by the peculiar mental
condition which accompanies this disorder, and is as much a
disease and removed from the patient's will, or control, as the
enlargement of the thyroid or the protrusion of the eyeballs.
There is also usually present catamenial derangement, and the
menses are scanty or hregular, in others profuse, and in some
patients leucorrhoea accompanied the menstrual disorders.

Sex, — Women are very much more Hable to this affection
than men, and from their emotional temperament this is not
unlikely. Von Graefe found only one man to every seven
women among patients affected Avith this complaint.

Age. — The period of life to which exophthalmic goitre
essentially belongs, is that bet^vixt puberty and the meno-
pause. It may be found over either limit, but rarely. In men,
adult life is also the period during which this affection mani-
fests itself.

Nature of the Affection. — It is now generally admitted that
this affection is a disease of the sympathetic or ganglionic
nervous system, and that the vaso-motor, or trophic, nerves
are the part most especially affected. There is disturbance

NERVOUS DISORDERS OF THE HEART. 279

of arterial and arteriole calibre by disturbed vaso-motor
action, here contraction and there dilatation. Thus the
arteries of the thyroid are dilated and enlarged until the
thyroid is almost an erectile tumour. So the prominence of
the eyeballs is due to a similar condition of the blood-vessels
behind the eye, with a development of fat-cells. The condi-
tion of the heart Niemeyer states confidently to be due to a
paralysed condition of the vaso-motor nerves of the coronary
circulation. The production of the disturbance in the heart
is not in all probability simple, and in addition to disordered
innervation of the heart, there is also obstruction to the flow
offered by this irregularity in the calibre of the vessels, and
thus the heart walls become dilated or hypertrophied, or
both. For dilatations of a tube, no less than contractions,
increase the difficulty of flow through it, and are obstructive.
The vaso-motor nerves are connected with the ganglionic
system, and so are the cardiac ganglia, on which depends
the heart's contractility, and there is reason to hold that their
action is somewhat diminished, and that the increase in size
of the ventricular chambers is partly the result of disordered
innervation.

The scalpel has not yet revealed the pathology of this
affection, nor has the microscope been any more success-
ful. It has been thought that an enlargement and redness
of the inferior cervical ganglion, with sparseness, dimi-
nished size, and fatty development among the ganglion
cells, would account for it ; but any pathology which can be
regarded as causative, or connected with this affection, other
than as results of it, is yet to be discovered.

In the heart fatty or amyloid changes are found, and
often valvular lesions, while the aorta and larger arteries
may become atheromatous ; the thyroid arteries may become
almost aneurysmal and dilated ; while a development of con-
nective tissue in the gland may lead in time to its becoming
smaller and harder; while in the eye, the vessels behind
may become diseased, the muscles of the eye degenerate,
and the lachrymal gland atrophied, probably from the same
cause as the thyroid.

Cerebral hsemoiThage has also been found.

280 THE HEART AND ITS DISEASES.

History and Duration. — The affection comes on from dis-
turbing causes, physical or mental in a manner not yet
explicable; and the favourite subjects are fair women with
blonde hair, blue or hazel eyes, with the temperament termed
by Laycock nervous, that is, there is high nervous suscepti-
bility amounting to hyperaesthesia.

The duration may be from a brief period of weeks to
years, and usually it does not cease till the menopause. Nor
in many cases is its duration shortened by remedies ; a cer-
tain alleviation may result from their administration, but the
temperament on which it depends is unalterable.

Prognosis and Terminations. — The prognosis as to time is
certainly not good, but as to life it is much better. Death
may result from intercurrent affections, some of which may
be traceable to the affection ; but others are not so associated.
The affections more distinctly traceable to the disease itself
are heart diseases with all the results which spring from its
failure, whether connected with valvular failure or disease of
the walls, cerebral hgemorrhage, or thickening of the meninges.
In some cases it seems connected with syphilis, and the con-
stitutional consequences which result therefrom cause death ;
but it can scarcely be said that these results followed from
the exophthalmic goitre, which was itself merely a conse-
quence of the general cachexia, and no more responsible
for the results than could be the exanthemata, which also
resulted from the acquired disease. In a disease so liable
fi'om its nature to be chronic, death must not uncommonly
occur during its existence, but these deaths may not in any
way be due to it, but quite unconnected with it,, and there-
fore in reading statistics of it, the deaths must not all count
against the disorder. It is not a fatal disorder in itself, but
death may result from it, but more often occurs during it.
Of 56 cases, von Dusch had 14 complete recoveries ; great
improvement in 20 ; no improvement in 4 ; 7 died ; and in 5
the result is unknown. Von Graefe had 12 per cent, of
deaths, 20 per cent, recoveries, 30 per cent, great improve-
ment, and 38 per cent, unknown. It is neither a fatal nor a
curable disease, as a rule ; and it is difHcult to comprehend
what condition remained after marked improvement or re-

NERVOUS DISORDERS OP THE HEART. 281

covery, as it is to understand how far the deaths were
connected with the affection.

Diagnosis, — This is frequently easy enough, the combina-
tion of heart disturbance, with goitre and exopthalmos, are
usually so marked as to make the diagnosis one of no difficulty.
But at other times one of these three may be wanting, or even
one only may be present, and then it is not so easy to make
a diagnosis. It is very desirable, however, to do so, as from
the known intractable character of the ailment it affects the
prognosis. Palpitation when associated with this neurosis
of the sympathetic, is much less tractable than when con-
nected with temporary failure, or the opposite condition of
vaso-motor disturbance with spasm of the arterioles, occur-
ring during limited periods. So this thyroid enlargement
is not to be cured as many are by iodine ointment ; almost
a specific in my experience of bronchocele common in my
native village.

The absence of one of the different component parts often
obscures the diagnosis, but in cases of doubt the mental or
emotional disturbances will often aid in forming a diagnosis,
and where the peculiar temperament is discovered, so allied
to the hysterical temperament, a clue to a diagnosis, as well
as a prognosis, is funiished. The temperament is incurable,
though some of its manifestations may be relieved. '^I'his
mental disturbance may itself be a source of danger to life,
as in self-destruction, or the mental balance may be so dis-
turbed as to result in mania.

In adflition to the mental condition there is another aid
to diagnosis, the " tache cerebrale " of Trousseau. This is the
production of bright red flecks or spots on the skin of the
head by slight irritation of the nail. This is a transitory and
localised paralysis of the vaso-motor nerves of the minute
vessels of the skin immediately under the surface irritated.
This phenomenon is precisely that of " blushing," which is
a momentary general vaso-motor paralysis, only it is localised.
Trousseau has deemed this a pathognomonic sign of this
" neurosis of the sympathetic " under consideration. This,
however, it is not ; but in establishing a diagnosis it must
not be forgotten.

282 THE HEART AND ITS DISEASES.

Treatment, — This is not a very satisfactory matter.
Digitalis is recomrQended by Trousseau, Oppolzer, and
others, and would seem to meet the condition of dilated
heart and dilated arterioles most exactly from its action, but
whether this condition of the sympathetic is unfavourable
to the manifestation of impressions on it, or these impres-
sions are not produced in its altered condition, or what, it is
not easy to say, but certainly it has not appeared to me, at
least, to have much effect on this condition, in which it re-
sembled all other specific treatment of it. Belladonna is also
a remedy of repute. Iron in anaemia is good ; but Trousseau
is not in favoui* of it generally. Preparations of iodine have
been praised, and the combination of it with iron, as in
Blancard's pills, is strongly advocated by Oppolzer and
others.

Remak recommends the use of the constant stream,
and the application of the magnetic current is consistent
with our knowledge of its action on hivoluntary muscles and
organic nerves. Where there is great cerebral excitement
and mental manifestations, bromide of potassium or ergot of
rye might be tried.

But the treatment resolves itself into the removal of all
causes Avhich might render a susceptible emotional system
more hyperaesthetic. Therefore psychical as well as physical
treatment must be adopted. The patient must, if possible,
be taught self-control, for her own comfort, all must be
avoided likely to upset her, excitement or bodily exertion.
Where there are catamenial derangements they must be
cured or amended, leucorrhoea must be checked, and uterine
affections subjected to their appropriate treatment. If the
condition or diathesis is itself beyond the reach of remedies,
the more need for relieving or removing what is within our
reach.

Choreic Paljntation — The condition of the heart in chorea
is yet unexplained : it has, however, many points of resem-
blance to the above disorder. Here the whole heart seems
also thrown violently against the anterior wall of the thorax,
which almost vibrates from the shock. In the absence of any
pathology to chorea, it is difficult to speculate even upon

NERVOUS DISORDERS OF THE HEART. 283

the immediate cause of the heart disturbance. This is
known, that the chorea of childhood and puberty, where
the nervous system seems somewhat to lag in its growth, is
a condition curable in time by nature or art, and the con-
dition of the heart improves with the nervine tonics, &c.,
which usually improve the general condition, among which
stand foremost arsenic and iron, and even more their
combination.

Hypercesthesia of the Heart. — This is a condition the oppo-
site of sub-paralysis, and consists of an uncommonly quick
pulse, quite compatible with perfectly good health. As,
however, a rise in the rapidity of the pulse is among the
prodromata of many affections, it is well to be guarded in an
opinion as to the rapidity of the pulse and its causation, until
the case has been some time under your own, or some other
observation, which can be relied upon. This condition is a
mere disturbance of nerve balance, a hypereesthesia of the
sympathetic, where the heart seems to be excited to contrac-
tion by very slight distension, and an unusually rapid pulse
results. How far it falls in disease or during an acute
disorder is not known yet, from want of the necessary obser-
vations ; and it is with the hope of attracting attention to
this matter that the writer makes this statement, for in the
exactly opposite condition of delayed or abnormally slow
pulse this may occur.

284 THE HEART AND ITS DISEASES,

CHAPTER Xm.
Combined Heart and Kidney Disease.

Part I. 1st Stage, From Kidney Disease to Heart
Changes: Effect of Imperfect Eliminations on Ar-
terioles— Hypertrophy of their Muscular Walls —
Effect of this on the Left Ventricle — Hypertrophy
— Arterial Distension and its Results — Symptoms —
Physical and Psychical — Grouping of Symptoms —
Anemia — Compensating Actions — Diagnosis — Progno-
sis AND Progress.

Part II. 2nd Stage. Heart Failure: Effect on the
Venous System — Secondary Affection of the Kidneys
— Symptoms (old and new blended) — Diagnosis —
Prognosis and Terminations. Treatment of 1st Stage
AND 2nd Stage:

Kidney Disease the Consequence, and not the Cause
of Heart Disease — Pathology —and Therapeutical
Indications.

The combination of disease of the heart with disease of the
kidneys has been a subject of considerable professional
interest since the days of Dr. Bright, whose name is so
inseparably connected with research on chronic renal disease.
It was first observed that hypertrophy of the left ventricle
was often found in cases of chronic kidney disease without
any apparent cause. Bright thought that the blood, altered
chemically by imperfect depuration, flowed with more diffi-
culty along the arteries Mr. James, of Exeter, had pre-
viously, so far back as 1817, pointed out that obstruction in
the small arteries caused a hindrance to the flow of blood
which, in its turn, led to hypertrophy of the left ventricle.
His view was that which was subsequently announced by
Bright, viz., "the altered quality of blood might so affect

COMBINED HEART AND KIDNEY DISEASE. 285

the minute and capillary circulation as to render greater
action necessary to force the blood through the distant sub-
divisions of the vascular system." In 1855, Traube published
some writmgs on the connection (Zusammenhang) betwixt
chronic heart and kidney disease ; but, unfortunately, he has
not published his more recent ideas, which are not quite
what he once held. The idea of the zusammenhang with
which his name is associated, is this 1st contraction of kidney
and impeded flow through it ; 2nd, obstructed arterial flow
in consequence of this; 3rd, hypertrophy of the heart.
Traube himself is aware that the muscular tunic of the
arterioles is thickened by hyperplasia in chronic Bright's
disease.

This most interesting discovery, which has done more
to unravel the previously mysterious connection betwixt
chronic kidney disease and hypertrophy of the left ventricle,
was first announced by Professor Geo. Johnson, of King's
College, in the 33rd volume of the Medico-Chirurgical Trans-
actions. After fm'ther observation. Professor Johnson found
that this thickening was always present. " In fact, it occurs
with the constancy of a physical law," he says in 1870
(Brit. Med. Jour., April 16th). Professor Johnson regards this
hypertrophy of the muscular tunic of the arterioles as due to
increased contraction of the small arteries, excited by the
abnormal quality of the ch'culating blood. This in its turn
excited hypertrophy of the left ventricle fi:*om the obstruc-
tion offered to the blood stream by these contracted arterioles,
the condition being general and "about equal in all the
tissues, the kidney excepted in some cases ; while in other
cases it seems to be greater in some tissues than in others."
Johnson's position is this, as to the relationship of the
diseases in heart and kidneys. 1st. Disease of the kidney,
and imperfect depuration of blood. 2nd. Arteriole spasm,
leading to hypertrophy in their muscular tunics, and ob-
structed blood-flow. 3rd. Hypertrophy in the left ventricle
in consequence of the obstruction to the blood stream. This
last' view is much more complete than Traube's, which is
generally held in Germany, though discarded by Niemeyer,
Bamberger, and others. It would scarcely be fair to Professor

286 THE HEART AND ITS DISEASES.

Traube to charge him with still holding his old views un-
modified, but I have no authority from him to state his
present views, which no doubt he will announce when it
seems fitting to himself. It is enough for the present pur-
pose that Professor Johnson's views are corroborated by
Dr. Quain, Professors Rutherford and Garrod, and Drs. Kelly
and Broadbent. When in Vienna I brought Johnson's views
under the notice of Professor Strieker, but, on mentioning
the matter to him on leaving Vienna, he declined to give any
positive opinion, as he alleged his observations were not
sufScient to warrant a direct expression of opinion. His
views, however, were more favourable then to Johnson's
than at first. In attempting to describe this combined con-
dition, the teaching of Johnson will be adopted here.

It must not be forgotten that a form of kidney disease
results from heart disease, a general interstitial infiammation,
with growth of connective tissue. As the first form of heart
disease from kidney disease merges, on heart failure, into the
second form of kidney disease resulting from heart failure,
and thus the symptoms special to each become blended and
so lead to confusion ; the subject will be divided into two
parts, viz., 1st. The changes from chronic kidney disease to
changes in the heart being established; and, 2nd, dating
from the time of the setting in of heart failure, the changes
Avhich follow from heart failure, and especially the effect
upon the kidneys.

Part I.

(Fro7n Kidney Disease to the establishment of Heart Disease.)

For a better understanding of the circulation through the
kidney, we are indebted to Virchow. And as the work of
Niemeyer is the best and most widely circulated medium of
communication betwixt German pathology and English
readers, the views, as announced in Niemeyer's chapter on
hypersemia of the kidney, will be adhered to here. The renal
artery has three divisions or branches, first the convolute,
passing into the cortical substance of the kidney, and con-
nected with the elimination of water through the thin-walled

COMBINED HEART AND KIDNEY DISEASE. 287

glomeruli in the Malpighian bodies ; second, the vasa recta
connected with the nutritive processes in the Vidney, and
also the elimination of urine solids ; and, third, an intermediate
set, both regionally and functionally, which partake of both
functions. The water is eliminated by simple pressure on
the glomeruli (Bowman), and then in passing down the
tubuli rmniferi, filtering from epithelial cell to epithelial cell,
becomes more and more charged with urine salts (Beale).
The effect of pressure on the glomeruli is increased by the
venous capillaries, if they may so be called (for they are
merely on the venous side, and do not contain venous blood,
but merely blood deprived of so much water), which are un-
usually narrow and of small calibre. This has two actions,
the one to obstruct the flow in the glomeruli, and so produce
more pressure and water elimination, and the other to dimi-
nish venous pressure in venous congestion.

This diminished bulk of lu'ine is connected with defective
arterial tension positively, and not with venous congestion,
offering obstruction to the flow. That is when in conditions
of impeded cir(;ulation, there is falling off in the bulk of
urine, it is not that there is venous congestion, but that the
veins being fuller of blood the arteries are emptier, and so
arterial tension is less, and elimination of water less. When
the abdominal aorta is tied below the renal branches, and
thus tension on the glomeruli increased, tliere is largely
increased bulk of urine, but without albumen, positively with-
out albumen, or alteration in amount of urine salts, they are
in equal amount, but in a higher state of dilution. Urine salts
are eliminated from the nutrient branches of the renal artery
apparently by a vital action in the epithelial cells. Ligature
of a renal vein produced an albuminous condition of urine,
with exudation casts and blood corpuscles (Frerichs).

These are important distinctions ; as increased arterial
tension, which we will see occurs in the first division of our
subject, is merely a difference of degree from ligature of the
aorta below the renal branches ; while venous stagnation, or
congestion from heart failure, is a mere difference of degree
from ligature of the renal vein.

In chronic Bright's disease, to follow Niemeyer's patho-

288 THE HEART A-ND ITS DISEASES.

logy, there is inflaraniation of the iinniferous tubule from its
Malpighian body downAvards, this is followed by atrophy and
destruction of it, its cells, and blood vessels, and usually a
growth of connective tissue around it. Thus a certain portion
of the kidney is destroyed for all functional purposes. There
is now a disturbance of balance betwixt the histolytic pro-
ducts of the body and their depurative organ the kidney. The
blood is now surcharged by an excess of the products of
retrogi-ade tissue-metamorphosis, normally present in it.
From this blood-poisoning follows a most interesting series of
compensatory changes, and however distinctly compensatory
they are, it must never be forgotten that a pathological, and
therefore necessarily downward course, is under considera-
tion. Consequently, while compensatory changes are spoken
of, it must not be imagined that they are perfectly compen-
satory, or not morbid actions, and that each compensatory
change though conservative in its way, and tending
to the preservation of life, and also to some extent of
health, has destructive consequences following in its wake,
inseparable from itself. Unalloyed good is not to be found
in pathological processes any more than anywhere else.
This condition of imperfectly depurated blood produces spasm
of the arterioles,* which are almost entirely muscular and
regulate the blood supply to the tissues, while at the same
time they convert the intermittent arterial flow into one
continuous equable stream. They are the muscular struc-
tures at one end of the circulaiion, the muscular heart being
at the other, and tubes, not entirely but practically elastic,
between them. Action goes on back and forward betwixt
these two, to some extent antagonistic, muscular termina-
tions of the arterial system, with what effect and result on
the elastic tubes betwixt them we shall see. This spasm of
the arterioles has one effect which must not be overlooked ;
by reducing the flow of bJood through the tissues generally,
it reduces the chemical interchanges, there is less muscular

* Ludwig, Traube, and others Bay that this is brought about by the effect oi'
retained urine salts on the vaso-motor centres, and have produced arteriole spa-sni
by injection of urine into Ihe blood. This vaso-motor centre has been deter-
mined by experiments of Ludwig, vcn Bezold, Thirry, Cyon, &e.

COMBINED HEART AND KIDNEY DISEASE. 289

and other waste, and thus the blood surcharged with waste,
and imperfectly depurated, is prevented from further poison-
ing ; that is, the depuration being imperfect, the amount of
waste is reduced for the time being, and thus the production
of waste products is diminished until the blood is again
restored to its normal purity, or impurity. Further contami-
nation is thus averted, and we see that the arteriole spasm is
conservative in its way. But this spasm leads to two results ;
obstruction to the arterial flow generally ; and to hypertrophy
of the muscular tunics themselves, from frequent spasm.

The obstruction to the blood flow in the arteries is kept
up by the thickened tunics (which are distinctly muscular,
and not to be confounded with amyloid deposit in them), and
leads to changes in the left ventricle. These may be divided
into hypertrophy, hypertrophy with dilatation, and dilatation.
Sometimes no change is inaugurated in the heart wall, but
here the ventricle can empty itself completely, in spite of
the spasm. In other cases imperfect ventricular contraction
leads to distension, and dilatation arrested by hypertrophy,
more or less perfectly, as seen in the chapter on Hypertrophy
and Dilatation.*

The existence of this thickening of the muscular tunics of
the arterioles in all cases, whether the left ventricle be
hypertrophied, normal, or dilated, most effectually disposes
of the hypothesis, to whom due I cannot remember, that the
arteriole thickening is a result of heart hypertrophy, and
compensatory to it. In a great majority of cases the left
ventricle is found hypertrophied. Here now we have con-
tracted arterioles, and a hypertrophied heart acting against
them. Thus the first pathological conservative action has '
led to another morbid change. Betwixt these two opposing
muscular changes we have increased arterial tension, and
this, by increased pressure on the glomeruli of the kidney,
leads to the prominent symptom, increased flow of urine.
The explanation that the increased flow of urine was due to

* A paper by the writer on the cause of hypertrophy, and showing its pro-
bable— to say the least of it — dependence on imperfect emptying of the ventricles,
and the effect of that on the trophic nerves, in the British Medical Journal
(March 2nd, 1872), may also be referred to.

U

290 THE HEA.RT AND ITS DISEASES.

increased pressure on the glomeruli remaining healthy, that
is, that the calibre of the renal artery remaining the same,
while its perij)heral distribution was diminished, there must
be more pressure on the glomeruli remaining sound, and
thus the bulk of urine increased, has been held to be unsound.
There is no difficulty in understanding this : this would
merely account for a bulk of urine equal to what existed
before the kidney disease. The increased tension, due
to the opposing muscular terminations of the arterial cir-
culation, is the cause of the increased bulk of urine. (It
differs not in character from the increased flow of water
produced by ligation of the aorta below the renal branches ;
or from the increased tension produced by a draught of
water, which augments the bulk of blood and causes greater
tension on the glomeruli, and increased elimination of
water, the amount of salts remaining entirely unaffected.)
This increased tension tells on the arteries in time, and
another morbid process is added to the rapidly widening
circle of troubles. The blood, pumped into the elastic arte-
ries by a hypertrophied left ventricle, while its efflux is
opposed by hypertrophied muscular arterioles, unnaturally
and unduly distends the elastic arteries. This leads to in-
creased recoil, as long as their elasticity is unimpaired, and
increased flow of blood into the coronary arteries and full
blood supply to the heart itself. Thus the hypertrophy of
the ventricle is maintained. But this increased distension of
the arteries leads to parenchymatous inflammation in or
under the brittle inner coat, or endarterium, and to the for-
mation of that condition known as atheroma. The diseased
arteries become elongated and widened from loss of their
elasticity, and from imperfect recoil on the extreme disten-
sion. This affects the whole arterial system, gradually and
slowly, but surely. During this time the increased arterial
tension mast itself be a source of danger, especially during
exacerbations of the affection, that is, at times there is more
imperfect depuration than usual, due to some disordered
innervation in the . kidney, probably, as we shall see in a
little time, spasm in the hypertrophied arterioles, and ob-
structed blood flow, leading to violent efforts (palpitation)

COMBINED HEART AND KIDNEY DISEASE. 291

in the hypertrophied heart to secure complete ventricular
emptying in the face of the obstructed flow.

This tests the arterial system, and the weakest point
may rupture ; and that weakest point is to be found in the
thin-walled arteries within tlie encephalon. Thus we get
great liability to cerebral haemorrhage, especially when the
flow forv\^ard is obstructed by thickened arterioles in a state
of spasm.

Cerebral haemorrhage may occur from increased heart
power alone, as in aortic insufliciency, without the effect of
arteriole contraction, Avhich adds most materially to the
danger of rupture and true apoplexy. Another morbid
action is now added to the list. Cerebral haemorrhage is
apt to occur at this stage, and is a great source of danger to
life practically. It is more apt to occur in hypertrophy of
the left ventricle, and is a direct consequence of that compen-
satory morbid action. For hypertrophy of the left ventricle
is a dh-ectly compensatory and conservative action to meet
obstructed blood flow. Where dilation results, cerebral
haemorrhage is certainly not so likely to happen, but then
we get other and surer mischiefs in its stead. The imperfect
circulation affects the system generally, for if the arterioles
cut off" the combustive changes, at one time a desirable
action, they also cut off the blood supply at other times,
when this impaired combustion is not called for. More
especially too this dilated ventricle does not distend the
aorta sufficiently to produce a recoil equal to overcoming the
resistance offered by its own thickened arterioles. It is im-
perfectly nourished itself, and grows weaker, and so less
perfectly nourished still, degeneration of structure follows,
and death from heart failure takes the place of danger from
cerebral haemorrhage.

The changes in the two muscular extremes of the arterial
circulation act variously, each at one time an advantage ; at
other times manifesting that they are pathological and not
physiological processes. Thus, during an acute exacerbation or
temporary increase in the usual blood impurity, the arterioles
contract and reduce combustion, and thus allow the system
to right itself of the accumulated products of histolysis ; but

u 2

292 THE HEART AND ITS DISEASES.

this repeated action leads to hypertrophy of their tunics,
constant obstruction to the blood-flow, and to generally im-
perfect combustion, and thus further accumulations of im-
perfectly oxidised tissue-waste. For, as Bence Jones points
out in his Physiological Essays, Bright's disease is a disease
of suboxidation. So we see, that a process conservative at
one time, is destructive at another. In like manner, when
hypertrophy of the heart occurs it balances the ch'culation,
and by increased power can drive an equal quantity of blood
through a smaller tube in an equal time. Thus ordinarily
the condition of normal health is closely approximated, but
during the exacerbations, when arteriole spasm is met by
violent ventricular contraction, the arteries are imperilled.
This danger is obviated when dilatation is present, instead
of hypertrophy, in the left ventricle, but, in place of danger
during exacerbations, we find imperfect power to overcome
arteriole action during the intervals, a general condition of
suboxidation, further and more frequent accumulation of
waste products, further arteriole opposition and greater
dilatation following ; and, consequently, not only a worse
condition to meet and undergo any intercurrent disease, but
positively a shortening of the time when heart failure will
inaugurate the graver conditions, to be considered in the
second section. Thus we see that the condition of hyper-
trophy in the left ventricle is a compensatory action sup-
positing lesser evils for greater ones, enabling the status of
normal health to be more closely approximated, and certainly
better enabling the system to midergo attacks of inter-
current disease than when dilatation is present. For when
dilatation is present there is not only a less power to undergo
intercurrent disease, but the general feeble condition and the
acpumulation of waste products in the blood, from suboxida-
tion, render the system more liable to intercurrent disease,
i.e., it is induced by more trivial exciting causes.

The exacerbations of chronic Bright's disease are curious
and interesting. As their patliology is not yet certain, the
subject must be spoken of with diilidence and caution. We
know, however, that dining the long period of life over
which this condition frequently extends, variations in the

COMBINED HEART AND KIDNEY DISEASE. 293

urine are a marked feature. At one time the patient passes
large quantities of pale-coloured urine of very low sp. gr.,
1*003 or so ; and at other times smaller bulks of urine than
the normal with a very high sp. gr., indeed laden with
waste products, urea, lithates, &g. Now, this is not a mere
question of dilution, and that an equal quantity of solids
give a low sp. gr. in large bulks of urine, or that the sp. gr.
is heightened when the bulk of urine is lesser than the normal.
There is a positive antagonism betwixt the amount of solids
and the bulk of urine. Nor is it difficult to conceive this,
for in the kidney we have seen there are two divisions of
lesser arteries, one-half connected with the elimination of
water, and the other with the nutrient processes and the
elimination of urine salts. It is obvious, then, that any
vaso-motor disturbance which would increase the circulation
through the one set by dilatation of its walls, would decrease
the circulation through the other set ; the calibre of the renal
artery remaining the same. There are variations of action
in healthy kidneys which we, apparently very rightly, attri-
bute to nerve action within the kidney itself; and these dis-
turbances are naturally more marked in a kidney the subject
of chronic disease, especially when its own arteriole muscu-
lar walls, the part affected by vaso-motor nerve influence,
are themselves the subject of hypertrophy. Thus we can
see without much difficulty thus far, viz., that these varia-
tions are likely to occur more commonly in chronic Bright's
disease than in health, and that the variations are more
marked too ; and, further, we can understand that all the
symptoms, resulting from the above-described pathological
condition, are more aggravated during the period of time
that the patient is passing large quantities of pale-coloured
urine of low sp. gr., and that relief is experienced when small
quantities of dense urine are passed.

Compensatory Actions. — When we remember the arguments
of Carpenter in his article Secretion, in Todd's Cyclopedia of
Anatomy and Physiology, viz., that each excretory organ is
capable of supplementing another organ's function, and of
eliminating materials special to another organ rather than
itself, a property which they possess as mere modifications of

294 THE HEART AND ITS DISEASES.

the general excretory surface in the lowest forms of life, we
can easily understand, that in the condition of chronic Bright's
disease compensatory actions in other organs, to supplement
the defective action of the kidney, are very common. As we
see the kidneys eliminate bile in cases of jaundice, so other
organs eliminate urine salts in Bright's disease. Thus we see
that not only are these sufferers more liable to intercurrent
affections from ordinary causes, but that they are also liable
to disorders of various organs, as ursemic diarrhoea, gouty
bronchitis, gouty eczema, gouty arthritis (which Bence Jones
says, truthfully enough, are compensatory peroxidations),
which are not morbid processes per se, but compensatory
actions. This is an important matter to bear in mind in the
treatment of various affections in these subjects. Not only
this too, but even affections arising a^s they do in sound per-
sons and without any reference to the cachexia, are apt to
assume a peculiar type, and persist as compensatory excre-
tory actions ; thus an ordinary bronchitis may assume a gouty
type, and will only yield to remedies which affect the cachexia;
and even an ulcer will assume this type and become " con-
stitutional," as the late Professor Miller of Edinburgh was
fond of terming it, becoming really an excretory organ, and
its surface eliminating. The histological elements of skin
are there, m another form merely, and we know from Funke,
that in the elimination of urea, the phosphates, chlorides and
sulphates of the alkalies, the constituents of sweat are those
of urine (Dickenson). The condition of imperfect depuration
of the blood thus leads to compensatory actions in other
organs ; and thus by reduced combustion, at times of great
impurity, and these compensatory actions, the system pre-
serves itself from such grave disturbance as must necessarily
be fatal, though sometimes a condition may be reached,
especially when a greater compensatory action than is com-
mon is required, when it seems almost impossible for the
patient to survive.

Symptoms. In the Heart. — Thus we see in this combined
condition of heart and kidney disease, that there are disturb-
ances in various organs, resulting from the pathological
changes, which may aid us in recognising this condition.

COMBINED HEART AND KIDNEY DISEASE. 295

Thus we find that heart symptoiriKS as palpitation, occasional
irregularity, are present, and especially during the exacerba-
tion ; when the presence of the stimulus in excess leads to
spasm in the hypertrophied tunics of the arterioles, increased
obstruction to the blood stream, and imperfect ventricular
systole and palpitation; the palpitation indicating the stress
upon the ventricle from distension.

Thus palpitation is a common symptom in this condition.

Arterioles, — This spasm of the arterioles is often manifested
by cold, " dead " hands or feet, so common in the sufferers
from chronic Bright's disease. Probably this same condition
in various tissues, muscles, tendons, or rather sheaths of
tendons, nerves, &c., leads to the various painful affections,
as rheumatism so-called, neuralgia, or sciatica, &c., and to
these wasting of muscles from too excessive spasm, found in
this condition.

Brain. — The brain is liable to suffer from the poisoned
blood on which it must feed, in chronic kidney disease, and
we find headache frontal, occipital, or vertical very common.
Vertical headache is a symptom of very great importance in
this condition, and is regarded as almost pathognomonic ;
indeed frequent and recurring vertical headache is a diagnostic
symptom of the greatest moment. Cerebral anasmia is com-
mon, and may be partial, or so marked as to simulate apoplexy.
It may only amount to a feeling of great prostration, ner-
vousness, and palpitation, due to imperfect evolution of nerve
. force by the anaemic centres, as martedly seen in the cerebral
anaemia, with melancholia, which accompanies poisoning
with bile products, as well ^s the other cause of arteriole
spasm.

At other times the condition of uraemic coma and convul-
sions may be produced; and it is yet an unsettled point
whether these are due to the positive presence of the poison,
or to the anaemia resulting therefrom, from arteriole spasm.

The mental manifestations will be considered further on.

Lungs. — There is a tendency to pneumonia from the
poisoned blood condition, which may fairly be regarded as
uraemic. But there are also curious " attacks of inexplicable
dyspnoea" (Basham) occurring in this combined disease.

296 THE HEART AND ITS DISEASES.

Niemeyer attributes this to oedema, of a transient nature,
but though this is probable enough in the later stages of
heart failure, it is improbable in the earlier stages. They
are more probably connected with spasm of the pulmonary
arterioles, as a form of apnoea.

Bronchi. — There is a liability to bronchitis, not only as a
compensatory action, but as induced by this condition.
Headlam Greenhow has shown the dependence of bronchitis
on gout ; and it is familiarly known that attacks of gout and
bronchitis alternate. Ordinary bronchitis may take on the
peculiar type, and be kept up by the constitutional condition.
In many cases litmus paper will be reddened, and positively
demonstrate beyond doubt that the mucus is no longer alka-
line, but acid. Winter cough and expectoration are also very
common here. In summer the skin acts freely, and the de-
fective action of the kidney is supplemented so completely
as to endow the sufferer with a very fair share of health and
strength as long as the hot weather lasts; but as soon as it
is colder the condition becomes worse, though eked out by
attacks of what is Called autumnal diarrhoea. In winter the
supplementary action has settled on the bronchial lining,
excited probably to some extent by the variations of tempera-
ture to which the bronchial lining membrane is exposed in
wiater. This is quite distinct from bronchial serous flow
from venous congestion common in the later stages. A long
fit of coughing, with expectoration, at rising in the morning
in winter, getting rid of the accumulations through the
night, is common here. We do not yet know the connection
betwixt gout and true spasmodic asthma, or if any connec-
tion exists.

Stomach. — Derangements connected with the stomach are
very common in chronic kidney disease ; not the gastric
cataiTh of venous stagnation depending on heart failure, but
a compensatory action. This is especially liable to show
itself during the periods of digestion, when the stomach is
normally acid, and is extremely intractable if the condition
on which it depends be forgotten. At other times we find
ura^mic vomiting, the vomited matters being of a urinous
character and smell, and Frerichs has claimed to have found

COMBINED HEART AND KIDNEY DISEASE. 297

masses of carbonate of ammonia in the vomited matter. This
ursemic vomiting is apt to occur in the gravest forms of
m*8emic poisoning, when the breath is also distinctly urinous,
and is regarded as a serious condition.*

Intestinal Canal. — The readiness with which the mucous
lining of the intestinal canal takes on compensatory action
is well known. In practice, action on the bowels to elicit
compensatory action is commonly resorted to in blood
poisoning, and especially in uraemia. Thus in the ursemic
condition wliich results from scarlatinal nephritis, purgatives
by mouth, or clyster, are commonly resorted to. Spontaneous
urgemic diarrhoea is not yet sufficiently recognised. This is
more common than is supposed, and often accompanies
acute congestion of the kidney. There is one difficulty in
the recognition of it, and that is the diminished renal secre-
tion. We are all so familiar with the fact that free purga-
tion, with dilated blood-vessels in the intestinal canal, lessens
arterial tension and renal flow, just as action of the skin
does, that diminution of urine is apt to attract no attention
as to its cause. This often leads to serious error in treat-
ment, and fatal results ; as pointed out by the writer in a
paper on Urasmic Diarrhoea (read before the Medicine Sec-
tion of the British Medical Association at Leeds, 1870).

Serous Membranes. — These are also liable to inflammation
in the course of chronic kidney disease, as pleuritis, pericar-
ditis, meningitis, peritonitis, and enteritis. Some persons
seem to have a special liability to affections of their serous
membranes in this state, and one relative of the writer's has
the symptoms of most acute enteritis and peritonitis which
seem as if about to be fatal. When profuse ammoniacal
vomiting and purging come on, then relief is at once expe-
rienced, and improvement sets in, followed by a brief period
of fair health, all things considered, until a feeling of malaise
for some days precedes another eliminative explosion. Were
it not that no attack has yet been fatal, the prognosis would

* My friend Dr. Charlton, of Newcastle, tells me he has found this condition
only tractable by carbolic acid, which he regards as the best remedy. He even
thinks if vomiting yield to carbolic acid, there is some ground for thinking it
uraemic.

298 THE HEART AND ITS DISEASES.

be unhesitatingly given of impending death, but the system
seems to become habituated to these compensatory dis-
turbances.

Joints, — The tendency for gout to settle in joints is well
known, and equally well known is the fact that the most
persistent form which retained products of histolysis assume
is that of uric acid. The explanation given by Bence Jones
seems the most satisfactory as yet. He thinks that uric acid
is rernoved from the blood, when circulating in excess, by fil-
tration into the tissues, especially chondroid; this proceeds
to a point when inflammation is induced, and the increased
temperature breaks up the uric acid into urea and water and
COg ; these soluble products dissolve, or are taken up by the
blood and excreted; a cleansing process by peroxidation
has removed \h.e waste products, leaving no trace on the
tissue, until repeated similar attacks have passed over them.
Thus, he says, the inflamed fingers and toes are converted
for the time being into supplementary kidneys. He regards
the inflammatory affections as pero^idising depurative pro-
cesses, occurring at intervals during the course of this chronic
disease of suboxidation. The general arteriole spasm of this
disease and its effect on combustion entitle it to be regarded
as a disease of suboxidation, and the good effect of these
peroxidising inflammations is apparent.

Hilton, in his work on Rest and Pain, has regarded the
heart as structurally homologous to a joint, and that it is
consequently affected by diseases which affect joints gene-
rally. Thus inflammatory attacks affect it in common with
other joints in tlic course of acute rheumatism, gout, pysemia,
&c. Endocarditis, and especially over the valves^ is, there-
fore, common in the course of chronic kidney disease, and
adds valvular lesions to the heart troubles arising otherwise
in this disease. It is more than probable that the force with
which both aortic valves (by aortic recoil) and mitral valves
(by increased ventricular systole) are closed when the blood
stream is obstructed by arteriole hypertrophy, and intermit-
tent spasm aggravating this action, is the cause of this
valvulitis, so associated with strain.

Skin. — The effect on the skin of chronic kidney disease

COMBINED HEART AND KIDNEY DISEASE. 299

varies. In some cases there is a decidedly dry, harsh state
of skin produced by the obstruction offered by the thickened
resistive arterioles, and here it is almost impossible to induce
diaphoresis, and Professor Johnson has found that cold by
inducing arteriole spasm, continued into palsy, and then
dilatation, the most effective means of producing diaphoresis
in these cases. At other times the skin, from its depurative
action being so closely allied to that of the kidney (Funke),
is liable to suffer from eruptions, and especially eczema, which
are eliminative in action. It may be made a question how
far the skin in carrying out its function becomes inflamed
and eruptions form, from the imperfectly depurated blood
with its excess of urine salts acting as an irritant ; or that it
is, from being fed on impure blood, more liable to inflamma-
tory attacks ; but certain it is that the eruptions are main-
tained by the excreta Avhich find here a channel. At other
times acute dermatitis, commonly called erysipelas (the non-
specific form), ensues, which may end in gangrene (Rosen-
stein), or the formation of ulcers. Carbuncles are commonly
found in gouty subjects, or these with Bright's disease.
Griessinger has thought purpura haemorrhagica to be con-
nected with chronic kidney disease.

The Hair, — As a mere modification of epidermis the hair
is affected in chronic kidney disease. Laycock says, that
when the hair is fine and soft it is apt to fall off, especially
from the vertex, and form a mere fringe round the skull,
like a monk's tonsure; where strong and thick it remains
full and strong, but loses its colour and turns rapidly white.
It is impossible to pay any attention to physiomonical diag-
nosis without being convinced of the correctness of Professor
Laycock's observations. In addition, I may venture to add
that intensely bright white hairs in a head covered with
profuse raven locks are very closely associated with chroni-
cally diseased kidneys, an impression much strengthened by
observations made in the Pathological Institute of Vienna.

The Ear-lobe. — Professor Laycock has laid stress on the
diagnostic value of a full, firm, red, rotund ear-lobe as an
indication of gout, and certainly it is a characteristic of
gouty families, and found in gouty people, and it is not easy

300 THE HEART AND ITS DISEASES.

r

to separate gout from chronic Bright's disease (Garrod).
In some small, dried-looking people with this renal disease
the ear-lobe looks withered and shriuiken, as if it suffered
from something allied to cirrhosis.

There are groups of pathological changes which indicate,
even to the eye, the existence of chronic Bright's disease. In
some there is a florid complexion, a full pulse with left ven-
tricle hypertrophy, atheromatous, dilated, capillaries on the
cheek, full alee nasi and ear-lobes, bald scalp, with a fringe
of grey hair extending from the temples round the occiput,
full temporal artery, a plethoric apoplectic constitution^ with
sanguine temperament, and hasty irascible temper. Along
with this are found uric acid sediments in the urine, and the
patient invariably gets up at night to make water. This last
symptom is curiously associated with Bright's disease, and,
when freed from sources of error as diabetes, imbibition of
large quantities of fluid at night, or later evening, may
fairly be regarded as pathognomonic.

In others there is a different grouping of symptoms. The
patient is thin, not at all plethoric, nervous, excitable, with a
' bushy head of grey or white hair, and with small, withered
ear-lobes ; apt to have gouty dyspepsia, jaundice, or skin
affections, and, if advanced of life, a well-marked fatty arcus
senilis. The patient has palpitation usually. Getting up at
night to make water is also found here. The general ap-
pearance of the patient is that of a withered apple, and gives
the impression of a general development of connective-tissue
which has shrunken and given this dried-up, wrinkled ap-
pearance to the tegument and external parts generally.

At other times the pallor of skin, so often remarked in
Bright's disease, is marked ; there is coldness of extremities,
and often " dead " hands and feet, chronic bronchitis, cough,
heart failure, dyspnoea easily induced, and the subcutaneous
areolar tissue fatty, and oedematous looking ; there is fulness
beneath the lower eyelids, and a watery looking state of the
tissues of the face, which often will become inflamed by ex-
posure to a sharp cold wind. These patients, usually females,
are the people so often met with in the upper and middle
classes, who catch cold on the least exposure, have facial

COMBINED HEART AND KIDNEY DISEASE. 301

erysipelas from facing a wind coming from cliurcli, are liable
to recurrent diarrhoea, or skin eruptions, are irritable, sleep-
less, and " whimmy." Here there is also nocturnal flow
of urine so marked as to attract the patient's attention.

Of course the sufferers from chronic Bright's disease do
not constitute three groups, or any other number of groups,
these are merely illustrations of people who have come
commonly under the writer's notice as subjects of this
affection.

The Eye, — There are changes in the eye connected with
chronic renal disease, as rapidly increasing impairment of
vision, want of accommodation in the eyes, and seeing
double, each eye having its own impression. The changes
to be observed by the ophthalmoscope are described as
usually white stellate spots on the retina, with a swollen-
looking condition of the retinal vessels. Rosenstein describes
the eye affection as retinitis, and it is also called retinitis
apoplectica in consequence of the tendency to the formation
of apoplectic dots, especially when the left ventricle is dis-
tinctly hypertrophied. The white spots are generally
attributed to formation of connective tissue, which is under-
going, or undergone, fatty degeneration. The subject is
considered at length in works on Ophthalmoscopy and
Diseases of the Eye, and .will be found in Clifford Allbutt's
book, or recent editions of J'ager. A form of ursemic cataract,
from infiltration of urea, allied to diabetic cataract, is also
found. The appearances in the eye are often such as to,
alone, justify the ophthalmoscopic observer in pronouncing
positively as to the existence of renal disease.

Kidneys. — The effect of the progress of this affection is to
influence the renal secretion. This is increased in volume,
especially in the middle stages of Bright's disease, so markedly
increased in volume as to be characteristic, and is a symptom
of value in diagnosis. There are also remarkable variations
in the bulk and sp. gr. of the urine, at times the bulk is
extreme, and the sp. gr. very low indeed; at other times
the bulk of urine is abnormally small, and the amount of
urine salts disproportionately large. It would seem that
there are more marked results of nerve-disturbance within

302 THE HEART AND ITS DISEASES.

the kidney itself in this condition of hypertrophy of the mus-
cular walls of the arterioles than there are in health. That
nerve disturbance, how induced cannot yet be detected,
causes these variations is almost beyond doubt. For though
increased tension occurs and would produce increased pres-
sure on the glomeruli, if the renal arterioles did not share in
the general vaso-motor spasm, and consequent hypertrophy,
still when the renal arteriole walls are also in action, this
increased tension is met by diminished calibre in the vessels
leading to the glomeruli; we cannot then attribute the
increased bulk of urine to mere increased tension in the
paroxysms. There is evidently at that time spasm of the
nutrient branches, and thus the calibre of the renal artery
remaining the same, increased blood circulation through the
convolute branches. This leads to imperfect elimination of
urine salts by the distribution of the nutrient arteries, blood
impurity increases, general tension is increased, and the
pressure on the glomeruli follows the greater arterial ten-
sion, and there is a still larger bulk of urine passed. The
attack passes off by diminished bulk of urine and large
amount of renal salts. The spasm in the nutrient arteries
gives way in time to dilatation, and then the position is
reversed, the nutrient arteries and arterioles are dilated, and
the calibre of the renal artery remaining the same, there is
increased flow through the nutrient vessels with large
elimination of urine solids, while the circulation in the con-
volute vessels is lessened and the bulk of urine dimmished.

The nerve-disturbance within the kidney is the com-
mencement of the paroxysm, and the consequent more
imperfect depuration of blood keeps it up.

And now as to the increased bulk of urine normally, if
the expression may be permitted, existing in developed
Bright's disease. We have seen that the calibre of the renal
artery remaining the same, but its peripheral distribution
being diminished by chronic destruction within the kidney,
the pressure would be increased in what remained sound,
and the bulk of urine be the same. But it is increased ! It
is evident then that there must be increased arterial tension,
and thus increased pressure on the renal artery and its dis-

COMBINED HEART AND KIDNEY DISEASE. 303

tribution. 'J^his would be accounted for by the hypertropbied
left ventricle so commonly found. But more observations
are necessary, and some very exact ones are desirable as to
the existence of this increased bulk of urine, along with
hypertrophied left ventricle, and as to what eifect is exercised
by a dilated left ventricle. The observations and experi-
ments of Phaff, Winogradaflf, Goll, Ludwig, and Traube, are
demonstrating the connection of water elimination by the
kidney with arterial tension, almost beyond question ; and
the effect of cardiac dilatation on the bulk of urine in chronic
renal disease ought, therefore, to be conspicuous. If found
to diminish the bulk, while hypertrophy increases it, it would
go far to remove the excessive water elimination from the
kidney itself, and locate it in the heart, which is secondarily
affected.

That the bulk of urine should ultimately in the later
stages be diminished, it is not difficult to comprehend, when
we remember that the heart hypertrophy fails when the
arteries become extensively diseased, and that then there is
venous congestion, which diminishes arterial tension, for the
fuller the veins, the emptier the arteries, while the auxiliary
forces of more extensive kidney disease, and the massive
hypertrophy of the kidney arterioles themselves (Johnson
says the kidney arteriole muscular hypertrophy is often more
marked than is that condition elsewhere), must aid in pro-
ducing diminished water elimination ; these combined forces
much reducing the pressure on the glomeruli.

Y^e can also understand that suppression of urine, the
ischuria renalis of Mason Good, may result from spasm of
the hypertrophied tunics of the convolute kidney arterioles.
Indeed it is difncult to understand how so purely physical
an action as water filtration through the glomeruli of the
kidney could be arrested, except by completely cutting off
the blood from the glomeruli. In this case we must see that
there would be rapid circulation through the vasa recta, or
nutrient branches, else there would such congestion of the
kidney ensue as must necessitate complete disorganisation ;
consequently there must be free blood supply to the nutrient
branch-distribution and to the epithelial lining of the tubuli

304 THE HEART AND ITS DISEASES.

uriniferi ; but without water to wash out the salts none can
be removed. This condition with its subsequent blood-
poisoning, uraemia, diarrhoea, vomiting, and other compen-
satory actions, is not unfrequent in the course of chronic
Bright's disease.

But as to increased flow of urine at night and the patient
having to get up to make water, it is inexplicable by any
action within the kidney, or question of increased pressure
on the kidneys from their more dependent position below the
aortic blood column, raised on the spinal vertebrae, in the
recumbent posture. Is it an actual increase at night? or
that the urine flow is more noticed, from the trouble of
getting out of bed which it entails ? This question must be
decided ere we can seriously seek for the explanation of a
condition which is not as yet an ascertained fact. That the
bladder is more intolerant of a diluted urine than a dense
one, we have the word of a very competent authority, Sir
Henry Thomson ; we can understand a bladder more rapidly
filled, owing to the general water elimhiation here being
increased, with a fluid of which it is less tolerant, the water
being of low sp. gr. of this condition, making its solicitations
more urgent, and necessitating attention to its calls. But
do the sufferers equally get up to make water during the
time of exacerbation with large bulk of dilute urine, and
also in the opposite condition of small bulk with great
density ? That getting up at night to make water is one of
the most common and trustworthy symptoms of chronic
Bright's disease is well known, let its explanation be what it
may.

There is also often seen an increase in lithates and in uric
acid itself in this disease. And whether urea and uric acid
are formed from the earlier products of histolysis, as creatine,
creatinine, &c., by the kidney itself, as the experiments of
Zalesky and others would tend to show ; or are eliminated
from the blood by the kidneys merely, as other experiments
would seem to assert ; it is equally certain that extensive
kidney disease impairs the elimination ordinarily ; and during
the periods of dilatation of the nutrient arteries and dense
urine, lithates and uric acid itself are commonly found.

COMBINED HEART AND KIDNEY DISEASE. 305

Uric acid is a result of imperfect oxidation we are gene-
rally taught, though Prout thought it the histolytic termi-
nation of gelatinous textures, and consequently it is here,
free, or in combination with some base, soda, potash, ammo-
nia, or lime (Rosenstein).

A sln-ewd north country doctor, the late Dr. Pearson, of
Penrith, gave the prognostic value of these sediments very
shortly : " It is all right when you do see them, but the
trouble is when you don't see them ; " and it is not easy to
improve on this. Calculi in the tubuli uriniferi are found
sometimes, usually black, and sometimes in cystic kidneys, as
large as peas, or they drop into the pelvis of the kidney, and
grow there, or pass down the ureter, often giving no little
pain in doing so, and either lodge in the bladder and increase
in size, or pass out by the urethra. Uric acid forms large
crystals out of solutions, and these are found in the urine,
after it has stood and cooled, large enough to be recognised
by the naked eye ; much resembling coarse Cayenne pepper
grains.

Sometimes the imperfect oxidation results in the forma-
tion of oxalates, now regarded as a mere modification of
urates, with an identical significance.

Tube Casts. — These are the most convincing evidences of
chronic Bright's disease when found. But even to this
evidence there are drawbacks ; firstly, they are very difficult
to find very often, being in much smaller numbers than in
catarrhal, otherwise called tubular, or desquamative nephri-
tis ; and, secondly, when found can give no information, as to
the amount of kidney diseased, or as to whether the disease
is common to both kidneys or confined to one.

These are serious drawbacks, and leave us in great doubt
as to the amount of disease present, which must be gathered
or surmised rather from the general symptoms. The casts
are small and granular, apt to be broken from their brittle-
ness, either in the uriniferous tubules, or elsewhere, including
under the glass cover of the microscopic slide, and are then
found in small masses. Their appearance and the changes
in their appearance, are well given in Beale's book. When
new cylinders are found, the exudation casts, or fibrin-cylin-

X

306 THE HEART AND ITS DISEASES.

ders, they testify that some new portion of kidney is being
impHcated, and along with them will be found albumen.
During the later stages, to be considered in Part II, these
exudation casts are common, resulting from venous stagna-
tion.

Albumen. — The first discovery of albumen in urine was
hailed as an infallible test for kidney disease, whose utter-
ances were unmistakable. The presence or absence of
albumen in urine are not now so confidently regarded as
aids to diagnosis. It is a well-known fact that in chronic
parenchymatous, diffuse, or interstitial nephritis, as it is
variously named, albumen may be absent for long periods ;
and that when it does occur, it is usually slight in amount.
Without entering into the difficult question of the diagnostic
value of albumen in the urine, it may be desirable to briefly
consider it here as far as it bears on the subject under dis-
cussion. In the first place, its absence for long periods
proves most conclusively that it is not an accompaniment of
a structurally altered kidney, where one or more localised
tracts are destroyed and en capsuled by connective tissue ;
this is no more than we could conjecture from reasoning on
the matter. This portion is utterly cut off from all possible
function, and can, therefore, have no symptom derived from
disturbance either in its function, or in what it was once
functionally connected with. While as to increased arterial
tension Niemeyer and Rosenstein alike assert that no albu-
men has ever appeared, in the urine, in all the experiments
of ligaturing the aorta below its renal branches. Increased
arterial tension does not, then, produce albuminuria. There
is only one conclusion on the matter, and it is this, albumi-
niu*ia, in chronic Bright's disease, indicates the implication of
a hitherto unaffected piece of kidney : it demonstrates that
another tract is being added to the portion previously de-
stroyed. Thus it is usually found in small quantities and
with a few exudation casts, or fibrin-cylinders. These signs
indicate an extension of the disease, and therefore are of
evil prognostic, as well as diagnostic import. Albumen may
indicate a more general implication of the structure of the
kidney at other times, and is constantly present in the later

COMBINED HEART AND KIDNEY DISEASE. 307

stages of venous congestion. But in the diagnosis of chronic
Bright's disease, while the heart is strong and equal to its
labour, we derive no aid from albumen in the urine ; its
absence can give us no comfort, nor does its presence tell us
how much previously sound kidney is being involved. During
the ordinary progress of the case albumen is ever absent from
the urine.

The varying amount and quality of urine, its increase in
bulk, and its call at niglit, the occasional suppression, com-
plete or incomplete, must often be the sole indications derived
from the kidneys themselves ; excess of lithates or oxalates,
at times, and albumen and tube-casts (exudation) aiding us
at intervals. Old granulation casts are found with too
much difficulty to be commonly at hand, but speak positively
to the existence^ but not to the extent of disease.

Dropsy. — This is not a characteristic of chronic kidney
disease so much as acute attacks of nephritis. It is rather con-
nected with the face than the lower extremities, which are the
earliest seat of oedema from heart failure. It is more marked
in the face in large white kidney than in small granular kid-
neys. In the latter it is only usually found as a slight puffiness
beneath the eyes ; while in some cases it seem« to exist as a
watery state of tegument, and with serous flow, readily in-
duced. At other times it is more general, even when there
is good action of the heart 'and firm incompressible pulse. It
is not here to be confounded with the more truly cardiac dropsy
of the later stages, which is merely modified by old kidney
disease. Long arguments have been entered into as to how
dropsy thus occurs, but no satisfactory emergence has yet
been achieved. It has been supposed that the amount of
urea in solution causes the water to readily leave the vessels
for the areolar tissues ; dropsy is certainly at times a sort of
compensatory excretory action. Bristowe (Croonian Lectures,
British Medical Journal, April 27, 1872) says of retained,. or
rather non-eliminated water, in chronic kidney disease, " a
great deal no doubt passes into the connective tissue, and
accumulates there, the capillary system throughout the body
acting as a kind of general excretory organ, and hence re-
sults general dropsy ; " and with the expression of the fact

X 2

308 THE HEART AND ITS DISEASES.

we must, at present, rest satisfied. That dropsy oocurs even
with good heart power and free evacuation of water is one
of the circumstances about it which is most inexphcable ; and
altogether the subject is not an easy one. The younger
reader, who wishes to know more about dropsy and its rela-
tions, can profitably and pleasantly spend some spare time
in perusing and conning the pages of a very excellent book
by Basham, " On Dropsy, and its Connection with Diseases of
the Kidneys, Heart, Lungs, and Liver."

Mental Manifestations. — When first beginning to study
chronic kidney disease, and especially in reference to heart
disease, the writer was struck with the occasional irritability,
active and positive, manifested in the subjects of this diseased
condition. It was not the imperfect thought of the anaemia
of heart failure, which is rather a condition approaching
amentia, and depends on lack of arterial blood, but a condi-
tion of mental activity presenting some peculiar features.
Lritability, disorder of temper, amounting to positive un-
reasonableness, great annoyance at small matters, which
" put them out " to ah extent quite disproportioned to the
slight exciting cause, characterise this afiection and especially
its exacerbations. A dear relative of the writer's used to
describe it pithily by saying that " she could fight with a
feather." The positive mental suffering and annoyance are
aggravated by a consciousness that there is unreasonableness
in it, and that it is a something morbid. This condition
completely baffled all speculation until a peiiisal of Bence
Jones's Physiological Essays, where the connection of this
irritable mental condition with oxaluria and retained lithic
acid was described. There is no doubt this mental irri-
tability arises from the brain cells being fed by impure
blood, and that the retained products of histolysis are the
foundation of it. Since then more accurate and extended
observations enable me to speak positively to tin's associa-
tion, and to connect periods of unusual irritability with
paroxysms of exacerbation, when the patient passes large
quantities of pale urine of very low specific gravity ; much
alleviation being experienced when the spasm yields, and a
discharge of urine of small bulk, but intense saturation fol-

COMBINED HEART AND KIDNEY DISEASE. 309

lows. Tlie effect is to disturb the mental equilibrium, and
has different results, sometunes not altogether unfortunate,
but most decidedly to be regretted.

It seems possible to charge some mental actions, other-
wise inexplicable and unaccountable, to retained urine salts,
and especially to uric acid, a conclusion perhaps more accept-
able to charity than likely to be accepted by psychologists.
It would often be satisfactory and agreeable to explain
anomal'ous and indefensible acts by this theory, and lay some
of human frailty to the charge of uric acid.*

Before proceeding to the diagnosis and prognosis of this
combined condition, it may be instructive to some readers to
sketch an outline of some cases as they present themselves
in practice. No completeness is aspired to, either in detail or
variety of groupings of symptoms, but just enough to aid
some younger readers to understand some cases which may,
without these hints, give them much trouble, often futile.
This has the advantage over long clinical cases of occupying
less space, if not quite so satisfactory. These are mere out-
line reminiscences of cases which gave great trouble till the
clue to them was obtained.

Nervous. — A person of good nervous development, or
rather of the nervous diathesis of Laycock, when suffering
from an exacerbation presented the following charac-
teristics : — Vertical headache, great and unusual mental
irritability, marked sleeplessness, not due to the headache,

* It may seem somewhat out of place to allude to impressions formed by
the writer as to the effect of retained urine salts on mental processes here, even
in a foot note ; but this excess of urine salts does seem to have a stimulant
effect on the brain, and gouty people are usually possessed of some talent. The
conclusions, so far, seem to indicate that many persons of good brains, but
lacking in energy and inclination to think, are stimulated by retained uric acid
into excellent thinking, and attain a reputation late in life. While in others,
■with small irritable " foxy " brains, the disturbing effect of these retained
excreta makes the cares of business, &c., quite intolerable. Retirement from
business at first gives relief; but soon this irritability incites them to have
something to do, and this too commonly is effected by becoming members of
boards and committees, when this mental irritability takes the form of mis-
chievous perversity, of ill-controlled interference with everything and every-
body. In this condition they remind the writer of nothing so muchjas a
cancerous gland — no longer fulfilling any useful purpose, but merely a source of
irritation to everytliing around them.

310 THE HEART AND ITS DISEASES.

which was not pronounced, great flow of pale unne of low
specific gravity, palpitation, loss of appetite, and general un-
easiness. Usual state : active habits of mind and body, witji
a dilated heart with some hypertrophy. This peculiar
grouping of nervous symptoms recurred again and again.

Sleeplessness. — This is a marked characteristic of chronic
Bright's disease. It is not connected with pain or bodily
discomfort, but is provokingly persistent. It seems due to
the irritation exercised by impure blood, and is aggravated
by thinking ; which is ever unsatisfactory, inconclusive, and
tending to work round and round in a circle, the same point
being reached over and over again, but no conclusion ever
attained. This condition becomes even more marked when
heart failure entails imperfect supply of arterial blood as well
as a spanaemic condition. For the blood tends to positive
thinning, anaemia, as well as containing excreta in excess.

Diarrhoeal. — Here was a good physique, with high
nervous development. There was marked hypertrophy, arte-
rial atheroma, large elimination of pale urine, great mental
irritability, aggravated in a paroxysm, and during the
paroxysm a nervous characteristic cough, excitement, and
supplementary catharsis. Thti diarrhoea for long protected the
patient, who suffered from ohe attack of cerebral hsemorrhage,
until a general peroxidation or inflammatory eliminative
action, commencing with erysipelatous inflammation of the
integument, with sloughing ; and ending in a typhoid con-
dition, with incomplete suppression of urine, and uraemic
diarrhoea, which terminated fatally.

In others dyspejDsia Avill be combined with the general
symptoms of Bright's disease, the peculiarities in the renal
secretion, irritability, often with atheromatous capillaries in
the cheeks : this chronic dyspepsia during the paroxysms
becoming aggravated, with acid eructations. This pyrosis or
water-brash is regarded by Rosenstein as very common in
diffuse nephritis.

Bronchitis, generally sub-acute, and at other times acute,
usually most marked in winter, will be found in other cases.
It is aggravated by sudden falls in temperature, and arrested
action of the skin. The accompanying symptoms or its

COMBINED HEART AND KIDNEY DISEASE. 311

interchange with attacks of gout, a well-known interchange,
will usually indicate its nature. It is quite unconnected with
the serous flow from the bronchial veins in the venous con-
gestion that follows the heart failure which inaugurates the
second stage, according to the division here adopted.

This susceptibility to changes of temperature in the sub-
jects of chronic kidney disease is decided and unmistakable.
Dickenson in his work, " Albuminuria," alludes to this, and
states its more marked character than the similar condition
of chronic rheumatism. In the subjects of Bright's disease,
sudden changes of temperature, by arresting the compensa-
tory action of the skin, will often produce the most serious
consequences ; and a sudden fall of temperature will often
furnish simultaneously a group of patients so troubled, each
with their characteristic compensatory action, or so-called
recurrent ailment.

In other cases there is found a condition simulating mus-
cular rheumatism, often accompanying arthritis of the hip
joint. There is general muscular pain and stiffness, or
perhaps a group of muscles only are affected, with, some-
times, wasting from prolonged arteriole spasm, inactive skin,
free flow of pale urine, great susceptibility to cold; and very
frequently those curious pains which herald changes in the
weather, and are probably connected with the magnetic per-
turbations which are the usual precui*sors of atmospheric
clianges.

At other times a patient will present these combinations
of peculiar renal flow, especially at night ; sleeplessness,
physiogmonical indications, with heart hypertrophy and
aortic atheroma, Avho is subject to recurrent inflammatory
attacks, pleuritis, pneumonia, enteritis, &g. Here the con-
comitants will indicate its connection with the cachexia of
chronic Bright's disease.

One singular manifestation is liable to occur in the course
of this chronic disease, and though it is not quite in place to
consider the various views of uraemia here, it is scarcely
possible to avoid it in order to put the question fairly before
the reader. Uraemia and ursemic coma are discussed by
many English writers, and Roberts, in his work on Diseases

o

12 THE HEART AND ITS DISEASES.

of the Kidney, gives a good resume of the views held by
various writers ; while the philosophic essay of B. W.
K-ichardson, in his asclepiad, may be studied with advantage,
and other recent articles are of value. The exposition of
Rosenstein as to the various views held, will be followed
here with some additions to its variations.

Theory of Urcemia. — When the chemical results of me-
chanical changes, to use the phraseology of Bence Jones,
first were studied in reference to the peculiar cerebral attacks
found to frequently result from chronic renal disease, it was
conjectured by Christison, that blood-poisoning by urea in
excess, was the cause of the brain symptoms. ''Owen Rees
thought it due to hydraemia, from thinning of the blood ;
and Osborne regarded the cause to lie in the membranes of
the brain being affected, as by arachnitis, &c. The view
of Christison found most favour. Some time afterwards
'Frerichs enunciated his well-known views of the decomposi-
tion of urea into carbonate of ammonia, being the cause of
the symptoms. This view has circulated most extensively,
but though it has been supported by Vogel, Petroff, and
others, Hammond, in America, and B. W. Richardson, in
England, have effectually demonstrated the unsoundness of
Frerichs' view ; wliile Zalesky followed Petroff 's experiments
without arriving at his conclusions. Injections of urine into
the blood are supposed to insure ursemic attacks more cer-
tainly than injections of urea (Rutherford Haldane), and
Vauquelin and Segalas tried unfiltered urine, and produced
death by mechanical plugging of the capillaries of the lung.
Filtered urine in the hands of Courten, Gaspard, and Frerichs,
produced no head symptoms.

Further experiments were performed by Meissner and
Voit, Oppolzer, Hoppe, Stannius, Schottin, Scheven, Perls, and
Zalesky, with the result of finding these head symptoms
follow nephrotomy or -ligature of the ureters. From Zalesky's
experiments, it would seem that nephrotomy or ligature of
the renal artery were very quickly fatal, and the earlier pro-
ducts of histolysis, creatine, creatinine, &c., were found in
the muscles and blood ; while on ligature of the ureters the
kidnevs still seemed to exercise some function in converting

COMBINED HEART AND KIDNEY DISEASE. 313

these earlier products into the more oxidised ones, urea and
uric acid ; which seemed to affect the result by being less
rapidly fatal than the earlier products, when in excess. From
this we may conclude pretty certainly that the earlier pro-
ducts of histolysis are more active than the more advanced
ones. In addition to these views of a poison in the blood,
the hypothesis of anaemia from hydraemia and loss of albumen
has been started. Then the theory of anaemia from effusion
into the brain substance (Gehirnoedem) has been evolved by
Traube, who has found this cerebral oedema ever present in
fatal uraemia. His view is that there is effusion into the
brain substance, and being enclosed within the bony cranium,
not allowing of expansion, the result was compression of the
blood-vessels and cerebral anaemia. Rosenstein's conclusion
is that Frerichs' carbonate of ammonia hypotheses mast be
abandoned ; and that the hypothesis of the head symptoms
being due to urea or other urine products, are doubtful and
improbable ; and that cerebral anaemia from brain oedema, or
otherwise, is most probable.

That in fatal uremic coma brain oedema is present, ac-
cording to Traube's theory, is admitted in La Charite, Berlin ;
but as to whether the brain oedema causes the anaemia, or
spasm and anaemia lead to oedema into the nerve structures
^vithin the skull, could be argued as long as either side
pleases ; and the argument of the cranium resembling an
inverted bell-jar, and consequently that atmospheric pressure
ensm'es its contents being ever the same in bulk, might be
appealed to by either side. If the spasm of the arterioles
lessens the bulk of arterial blood, some compensatory fulness
must follow, and vice versa, brain oedema must compress the
blood-vessels and produce anaemia. The conclusions which
seem to the writer most probable are these : 1st. That the
anaemia is due to arterial spasm ; 2nd. That this anaemia
causes the symptoms of convulsions and coma ; and 3rd. That
this leads to oedema in fatal cases.

For the truth of this hypothesis may be adduced the effect
of retained excreta on the vaso-motor system, and arteriole
contraction, which is left out in Traube's view of the brain
oedema producing the anaemia.

314 THE HEART AND ITS DISEASES.

Then in a typical case of uraemia, a well marked case,
which was the subject of a clinical lecture by Duchek, in
Vienna, the loss of consciousness and tremors, incipient con-
vulsions, were momentary and transient, like the lifting and
falling again of a cloud, and more in unsion with the idea of
intermittent spasm, or variations of completeness in spasms,
than the constant pressure of oedema. In tliis conditiori
recovery is possible, even when the spasm persists without
remission or intermission ; but oedema, effusion into the brain
substance, is a result which ensured death. In the cases
which do not terminate fatally, the diminution of arterial
bulk by arterial spasm is probably accompanied by venous
congestion, a condition not incompatible with recovery ; when
oedema sets in and produces persistent pressure on the blood-
vessels, death follows.

This discussion has taken up more space than was antici-
pated, and the fact that uraemia, as seen in the more acute
conditions of ursemic coma and convulsions, and in typhoid
symptoms, is rather connected with urea, or even the earlier
products of retrograde tissue-metamorphosis, creatine, and
creatinine, while the more persistent tissue changes and
chronic inflammations, of joints, &c., arise from uric acid,
must stand unsupported, and be left to its intrinsic truthful-
ness. These acute conditions are associated with the accu-
mulations of the more active earlier products of histolysis,
while the more chronic parenchymatous inflammations, &c.,
result from the most persistant form assumed by this tissue-
waste, namely uric acid.

Diagnosis. — This is not an easy^ matter, especially for
beginners, w^ho find it difficult to find the exact value of y
(the diagnosis) from an indefinite number of x s (the symp-
toms) of undetermined value.

The symptoms and signs which go to form the diagnosis
are numerous and of varying value, and their grouping and
association will often have to settle the question ; more or
fewer being found together, and then there is often a sug-
gestive relationship, which creates a fair presumption, casts,
ophthalmoscopic signs ; feeling the altered bulk of the

COMBINED HEART AND KIDNEY DISEASE. 315

kidneys being alone positive, and this is often imprac-
ticable.

We will proceed with a brief resume of the signs first.
In the diagnosis of diffuse nephritis Rosenstein places the
heart changes first. There is alteration in the left ventricle,
■usually hypertrophy, with decidedly accentuated aortic
second sound, without apparent cause, and commonly
increased impulse, &c. The pulse is hard, the radial artery
ngid, and the arteries atheromatous, the temporal often
being conspicuous, tortuous, and thickened. There is often
a dry harsh skin, with atheromatous capillaries on the cheek,
and "dead "hands and feet. The hair and ear lobe often
aid. At other times a thin skin, with fulness under the
lower eyelids, and apparently oedema in the subcutaneous
areolar tissue is found. These are the changes in the eye,
very positive when present. Variations in the bulk of urine,
with antagonism betwixt bulk and specific gravity, and the
curious symptom of getting up at night to make water, ever
suggestive, and associated with the general increase ui the
renal flow. Uric acid crystals, &c., in. the urine are of service
in determining the diagnosis at times, and casts settle the
existence of the disease, that is, old granular casts ; new
exudation-casts and- albumen mark new implication of pre-
viously sound kidney. In addition to these, in thin persons it
is possible to test the condition and bulk of the kidneys by
touch, and play the kidneys betwixt the hands and fingers
(Sir William Jenner's Lectures in Lancet, 1865). More or
fewer of these are present, and along with them some of the
following symptoms : — Palpitation, especially during exacer-
bations ; vertical headache, very important; sleeplessness;
mental irritability ; and occasional curious attacks of dyspnoea.
Disturbances of vision, as quickly increasing loss of vision, not
being a visible affection of the eye, double vision, occurring
in persons over middle age, are very suggestive. Then there
come the effect of variations of temperatures, and muscular or
other pains, recurrent attacks of gout, bronchitis, dyspepsia,
diarrhoea, vomiting, other distinctly inflammatory affections,
ever suspicious ; tendency to anoemia in some cases, and

316 THE HEART AND ITS DISEASES.

lastly, moi'e rarely, attacks of ureemia affecting the cerebro-
spinal nervous system.

Seoj. — Perhaps of the two sexes men are more subject to
Bright's disease ; but sex is absolutely valueless as a
diagnostic indication.

Age. — Advancing age ever gives a predominance of de-
generative and chronic diseases ; it is not only more liable to
them, but survivorship entails even changes as time rolls ori.
Young people rarely suffer from chronic kidney disease,
unless preceeded by an acute attack, and the same holds
good of heart affections. Still both are found, not combined,
true, as diseases from which even intrauterine life is not
secured. The most common subjects ^re in middle life
and more advanced age. Of course in making any such
statement the fact is not lost sight of that the earlier and
less pronounced stages are usually overlooked, and that, too,
not from negligence on the physician's part, but in conse-
quence of the insidious nature of the complaint itself A^Hbien
this condition first commences is, in the majority of cases, not
only unknown, but positively un discoverable. We only de-
tect it usually by the oncome of the various changes which
follow in the wake of chronic kidney disease, or by the
accidental discovery of a characteristic tube-cast. Indeed,
the diagnosis is itself a surmise of greater or less probability ;
much depending on the skill, experience, and attention paid
to the subject on the part of the medical man himself. There
is a something in diagnostic skill not to be communicated to
anothei*, and, as Carlyle says, the eye can only see what it
has learned to see. The effect of individual experience, and
diagnostic as well as therapeutic ripeness in skill, are not to
be acquired otherwise than by the sweat of each individual
brow.

Proanofiis. — There is no more difficult matter, in this com-
bined condition of heart and kidney disease, than arriving at
a fairly correct prognosis. The different factors are to be
gathered from the elements constituting the diagnosis, the
condition of the heart, its maintenance of its own structural in-
tegrity, the presence or absence of dilatation; the character of
the renal flow in bulk and specific gravity, the probable amount

COMBINED HEART AND KIDNEY DISEASE. 31 7

of disturbance of balance betwixt the amount of tissue- waste
and the means to eliminate it, as gathered from the different
compensatory over-actions of organs, or eliminative peroxi-
dising inflammations, &c. There is no certainty, however,
that the destructive process is not more steadily going on in
those systems which are not disturbed by these intercurrent
affections, than where the system is often so disturbed. The
effect of these intercurrent attacks is to produce a cleansing
effect upon the blood, and they are thus useful ; while other
systems may be preserving a fair amount of bodily vigour,
and often great intellectual activity, as long as the supply of
arterial blood to the brain is good and fairly maintained ; but
in them a steadily downward progress of increasing degenera-
tion of one organ may be telling on another, and a general
unobserved molecular decay produced, which will manifest
itself in sudden failure of heart or arteries ; or in some inter-
current attack rapidly becoming fatal, and revealing the
unsuspected impairment. Indeed the prognosis must largely
depend on the peculiar circumstances of each individual case,
and to some extent on the skill of the practitioner in award-
ing to each symptom its true appropriate value. There are
still elements of error, which elude all calculation and fore-
sight, and the uttered prognosis must, in most cases, contain
a saving clause.

Intercurrent affections arise commonly in this condition,
and that is easily conceivable. For not only is the imper-
fectly depurated blood itself a source of irritation to various
tissues which put on ursemic inflammation, but also tissues
fed on this impure blood possess less resisting power to
withstand ordinary exciting causes of disease. The system
is more easily thrown off its balance, and the margin within
which the disturbed balance may safely rock, without exciting
disease, is distinctly diminished. Intercurrent affections are
more dangerous to life than when occurring to a perfectly
healthy person, in the first place ; and are also more likely to
persist in a chronic form, from taking on peculiarity of action
and becoming eliminating surfaces, and thus tend to assume
confirmed structural changes. Tlic prognosis of an inter-
current affection is worse than when the system is free from

318 THE HEART AND ITS DISEASES.

these consecutive morbid changes, though many of them are
compensatory and conservative.

A totally different prognosis exists, however, in those
intercurrent diseases, which may fairly be laid to the account
of the waste-laden, imperfectly depurated blood. Here the
system, though no doubt affected by the acute disease, is
really being relieved from an accumulation of waste, and the
inflammation is a depurative process. Many very grave and
serious illnesses in persons of .middle age and advanced life
are to be thus regarded. There is, too, in these cases a
tendency to recurrence, a point of some prognostic import-
ance, as well as diagnostically valuable. In such cases the
compensatory over-action, or inflammatory depurative pro-
cess, will often bring the patient to death's door, and leave
him there ; just as all hope must apparently be abandoned,
an improvement sets in, and gradually goes on to recovery.
It is like a disturbed balance, the most dependant point is
immediately followed by an upward rise. To a stranger
called in these cases are very difficult to estimate, ^nd no
one, stranger or not, can tell at which one of these attacks
the balance will be permanently overthrown ; and the point
of most depression no longer followed by an upward move-
ment. Repetition of the attacks must be allowed to influence
the prognosis, and the medical man who becomes familiar
with these attacks in his patient, is not so entirely devoid of
hope as a person not so familiar with them would justly feel.
Thus the old medical attendant in such cases from ex]3e-
rience of former attacks not being fatal,- however alarming,
gives a hopeful prognosis, which, being verified by the result,
gets him the credit of " knowing the patient's constitution ; "
and not altogether without deserving it. For though, per-
haps, he has had something else to do than meditate on
morbid actions and reactions, on compensatory actions and
conservative processes, as distinguished from morbid pro-
cesses, and is unacquainted with the most recent views- on
peroxidations ; he has learnt that in this particular case the
grave, and, apparently, almost necessarily fatal attacks seem
to exercise some peculiar effect over the patient, who not
only recovers from them, but seems positively to have a

COMBINED HEART AND KIDNEY DISEASE. 319

period of unusual good health for some time after each attack.
The recurrence of them seems to confer on the system a sort
of protection, from habitude, and these grave disturbances
would, in all probability, be quickly fatal in a system not
previously habituated to them. Mistakes are often most
instructive, and the recital of the following one may possibly
be of some service to younger readers, as it certainly has
been to the writer : — Some years ago now, the writer was
called in to attend an old lady of 72, who had pallor and
swelling beneath the lower eyelids, nigh t-voidings of urine,
great variations in its amount, and a dilated heart, with a
very irritable temper. There was also a history of preceding
attacks of nephria and albuminuria. She was suffering from
almost total suppression of urine (and the small amount,
which could be secured, was slightly albuminous, and con-
tained stray granular casts), and a profuse exhausting diar-
rhoea. Having some short time before been much taken up
with uroemic diarrhoea, the writer declined to arrest the
diarrhoea until the flow of urine was re-established. Acetate
of potash, spirits of juniper, and buchu were given, the skin
was acted on by hot bottles in bed (Sir James Simpson's
bath), hot poultices faced with mustard were laid over the
loins night and morning, and poultices without the mustard
continued during the intervals ; gin and water, milk, and
beef-tea constituted the sustenance. For two or three days
the case went on getting worse, ureous vomiting came on,
the breath had a distinctly urinous odour, sight was affected ;
delirium at nights, and a brown-coated tongue indicated the
oncome of typhoid symptoms, and the patient's children
were summoned. Just then an improvement set in, the urine
returned, and the diarrhoea ceased, and the indignant rela-
tives discharged the writer, with scant courtesy, as unworthy
of professional confidence. A consciousness of a not having
guarded the prognosis sufficiently carefully, would not allow
self-pride to assert too confidently that the want of con-
fidence was altogether unjustified. The c^se proceeded
uninterruptedly to a good recovery under the gentleman
called in ; and the lesson was laid by and pondered over. The
next attack occurred somL^ couple of years after, under

320 THE HEART AND ITS DISEASES.

anotlier medical rrian, who held no views as to compensatory
actions, and proceeded at once to check the diarrhoea, only
too successfully, and this time the depressed balance never
swung back, but remained permanently overthrown.

The attacks of apparent enteritis, or colic, ending in
copious diarrhoea, the motions soon becoming ammoniacal
(W. Koberts), the other serous inflammations, or attacks of
bronchitis, carbuncles, or other skin affections, gout, &c., are
often recovered from in a surprising manner. But, on the
other hand, intercurrent attacks from ordinary outside causes,
are more than ordinarily serious, while the effects of vaiia-
tions of temperature, and more especially sudden falls, are
very grave. The patient with chronic Bright's disease almost,
as it were, lives over a volcano, whose sudden explosions are
a source of imminent danger; and these explosions are most
commonly induced by sudden falls of temperature, which
check the action of the skin, and occasion a sudden accumula-
tion of uneliminated waste in the blood, and from that again
some very serious acute affection; the results of which may
be unfortunate and destructive to life. Thus a sudden fit of
intense cold will throw a number of these cases on the
doctor's hands together, and a heavy percentage of deaths
among them usually occurs.

Another source of danger is the risk of cerebral hsemor-
rhage. This is apt to be induced by a paroxysm which will
produce arteriole spasm, increased arterial tension, and en-
danger the elastic tubes which connect the two muscular
extremities of the arterial system, already perhaps somewhat
rigid and brittle. Thus Kirkes found 14 cases of cerebral
apoplexy out of a total of 22, to be accompanied by renal
disease, the kidneys, as a rule, being small, hard, and granu-
lar, and m 13 of them there was hypertrophy of the left
ventricle. And Eulenburg, in 6 cases of apoplexy, found 5
with cirrhosis of the kidneys and heart hypertrophy.

But though hypertrophy of the heart is thus productive
of apoplexy occasionally, it is a very important conservative
change, endowing the patient with a very fair share of bodily
health and activity, as compared to those cases where dilata-
tion exists with very impaired health. For heart failure is

COMBINED HEART AND KIDNEY DISEASE. 321

the inevitable fate, whose oncome may be deferred but not
averted ; and certain and positive increasing degeneration of
the circulatory organs must follow this disturbance in the
vaso-motor system : an unseen power has laid its arresting
hand on the peripheral circulation, whose importance must
not be underestimated. There is something weird in the
fairy touch on those minute vessels, which is gradually to
bring the circulation to a standstill for ever. The condition
is not one of precipitation, and much time may elapse, allow-
ing of many an intercurrent accident ; ere a point is reached
of positive degeneration in the heart itself, which inaugurates
a series of backward changes in its turn, implicatmg the
kidneys in common with other organs, and leading inevitably
to somatic death. The consideration of the manner in which
this heart degeneration is induced, and the consequences
which result from it, will engage our attention next.

Part II.

{From Heart Failure to Secondary Renal Disease,)

The pathological changes entailed by primary renal disease
with accumulation of waste-products in the blood, and their
effect on the vaso-motor centre ; the consequent spasm of the
arterioles, which in its turn led to hypertrophy of the mus-
cular tunics ; this obstruction to the blood stream entailing
changes in the left ventricle, usually hypertrophy, at first at
least ; and then the over-distension of the elastic arteries, be-
twixt the two muscular extremities, have been described
above ; and now we come to the time when this progress is
no longer sustained by compensatory changes.

The distension of the arterial coats, ever existing betwixt
the hypertrophied ventricle and arterioles at any time, as
testified by the increased bulk of urine, and aggravated at
intervals, by the arteriole spasm during a paroxysm, gradually
induces structural changes in the arteries. The brittle intima
or endarterium with its subserous tissue, becomes the subject
of parenchymatous inflammation, and young connective-
tissue corpuscles are developed, especially at points subjected
to unusual strain. This spreads along from the convexity of

T

322 THE HEART AND ITS DISEASES.

the aorta backwards and forwards. The whole of the larger
arteries become affected with this endarteriitis deformans.
The growth diminishes, by its own thickness, the calibre of
the aorta and its branches : this further taxes the heart-
walls.

This low parenchymatous inflammation gradually affects
the whole arterial thickness, the tubes lose somewhat of their
elasticity and recoil imperfectly after distension ; this leads
to their being elongated and widened : while their walls
become more rigid and less and less elastic. The temporal
artery can often be seen in this condition, meanderiug
along the temple, tortuous and serpentine. The arteries are
thus not only more liable to rupture, especially during excited
action betwixt the struggling ventricle and the spasmodically
closed arterioles, but their degeneration affects the heart
itself. In the first place the degeneration extends down the
coronary vessels, and of course, when so affected, they are
not so easily distended by the aortic recoil, their systole ;
while their elasticity being diminished, the circulation no
longer receives the aid it did receive when that elasticity
was unimpaired. The aorta itself loses its elasticity also,
and its recoil is much more imperfect.

Thus we see that while the heart has to act, or does act,
any how, against rigid non-elastic tubes instead of distensible
elastic ones, its own nutrition is affected. This no longer
enables the ventricle to empty itself perfectly, and imperfect
ventricular contraction leads directly to dilatation. The
condition is now distinctly worsening, and the blood is still
less perfectly depurated, being no longer so freely circulated :
this leads to further arteriole spasm, obstruction to the blood
stream, and further dilatation. The dilating ventricle no
longer possesses the power of the hypertrophied condition,
and less blood is thrown at each systole into the aorta, its
distenf^ion and recoil are less, and the coronary circulation is
still further impaired ; this involves less perfect nutrition to
the muscular structure of the heart, and ultimately structural
necrosis, or fatty degeneration results ; the worn out material
being no longer removed and replaced by new materials from
the impairment in the blood supply.

COMBINED HEART AND KIDNEY DISEASE. 323

We have now a distinct failure in tlie heart's power, and
distinctly defective circulation. Between the two muscular
extremities the heart and arterioles, i.e., the left ventricle
and the systemic arterioles, and the right ventricle and the
pulmonic arterioles, the equilibrium is deranged, and the
defective ventricles no longer counterbalance the peripheral
muscular distribution. The impaired aortic recoil alike affects
both right and left coronary vessels, and the right ventricle,
ever the thinner and more prone to dilatation, yields. This
is probably the first step in the congestion of the venous
system. The blood, in German phraseology, now lies more
on the venous side, and though this soon affects the arterial
circulation, the venous congestion remains unrelieved. The
venous congestion may obstruct the arterial circulation, and
increase the demand on the already over-taxed left ventricle,
but, unfortunately, that exercises no curative effect. We
have now venous congestion and some new pathological pro-
cesses entailed therefrom.

In the first place, we get obstruction in the renal vein,
and from that albumen and exudation tube-casts : for the
venous congestion differs from ligature of the renal veins, or
lower vena cava higher up, only in degree. But this is not
all, venous congestion affects the nutrient branches of the
renal artery, and impedes the flow through them, interfering
with the elimination of solids. While these positive results
follow from venous congestion, we get, negatively, diminished
bulk of urine. This does not result so much from venous
congestion, for the narrow continuations of the blood-vessels
from the glomeruli prevent its acting very strongly. It is
chiefly the result of diminished arterial pressure. Venous
congestion means diminished arterial pressure. The blood
lying in excess on the venous side, the arteries are not so
well filled: this tells on the arterial pressure, which is
lowered. We have then diminished bulk of urine.

Lessened arterial tension leads to lowered water elimina-
tion from the glomeruli, while venous congestion leads to
albumen, fibrin cylinders, or exudation casts, and diminished
excretion of urine solids.

A very serious point is reached when the urine becomes

Y 2

824 THE HEART AND ITS DISEASES.

permanently albuminous. The diagnostic import of this
sign is significant, and its prognostic import of the gravest
character.

This venous congestion leads to still more imperfect
depuration, the accumulated waste products cause still
further vaso-motor spasm, and thus still further tax the
heart, already handicapped most heavily by the obstruction
offered by rigid arteries, and the vis a fi^onte of venous con-
gestion ; while its structural integrity is impaired. The
hypertrophy which once preserved it from dilatation and
enabled it to contract perfectly, in spite of the opposition
offered, is being cut down irretrievably. The dilatation and
structural decay act and react, and ultimately the ventricle
halts, the halts become rythmical, then the halts succeed
each other ; the dilated rotten Avails become more distended,
and ultimately the heart stops, and all is over.

But this is usually a long and weary process, and the
heart struggles away, becoming gradually feebler and fainter.
During this time other pathological processes have been
inaugurated, and the venous congestion impedes the flow in
the portal circulation, being unpro^dded with and unprotected
by valves, and the viscera become subject to growth of inter-
stitial connective tissue, which impairs their functional
activity; while the lining of the intestinal canal becomes
congested, and often subject to serous flow. The same con-
gestion affects the bronchial veins, and then a serous flow,
so-called chronic bronchitis,' impedes the patient's breathing
and adds to his troubles. The results of venous stagnation
have been sketched before, in Chapter IV, and need not now
be repeated at length. The brain is now not only fed with
impure blood, but it is suffering from the defective arterial
flow, while the venous congestion is leading to structural
change by connective-tissue growth.

The venous stagnation leads to serous effusions, and these
may take place into any of the serous sacs from the ventri-
cles of the brain to the tunica vaginaHs, or the fold of Doug-
lass. These add to the circulatory difficulties, and are not
unfrequently the immediate cause of deatli.

Dropsy now shows itself, not purely cardiac, and proceed-

COMBINED HEART AND KIDNEY DISEASE. ' 325

ing from the feet upwards, but more irregularly ; indeed,
there is a combination of renal and cardiac dropsy. Whether
the blood laden with urea does pass more readily into the
tissues, than mere ordinary water-laden blood, as is stated
by some authorities, or not, is not yet determined. This at
least we know, that there is not the same order observed as
in uncomplicated cardiac dropsy.

W e now get more compound symptoms ; dyspepsia from
urine salts is complicated with gastric catarrh; attacks of
dyspnoea with oedema, chronic bronchial flow, difficult respi-
ration, and emphysema ; bilious disturbance comes on ; and
the sleeplessness of the first stage is complicated by drowsi-
ness and disturbed, unpleasant, and often terrifying dreams.
We find the free flow of pale urine of low sp. gr. now no
longer. The urinary secretion falls below the normal, and
the scanty urine is laden with urine salts. Frerichs on tying
the renal vein found the bulk of urine reduced more than the
elimination of salts in proportion to each other. But even
without experiment this would be manifest ; for the blood
circulating through the kidneys is overladen (iiberladen)
with histolytic products. Thus the scanty urine is laden
Avith lithates, imperfectly oxidised products of tissue-waste,
while it now contains albumen, permanently, and both old
granular and new exudation tube-casts. This change in the
symptoms derived from the urine cannot, I trust, be a source
of difficulty to the reader after the above explanation. The
diminished bulk of water from lessened arterial tension, and
the albumen and tube casts (new) from venous congestion
ought not to create confusion ; both depend on failing heart
power.

The profase flow of urine which characterised the first
stage of the disease, of the increased tension produced by an
hypertrophied left ventricle and hypertrophied arteriole mus-
cular walls, is now modified by heart failure and the lowered
arterial tension. The bulk falls gradually as the case goes
on, and the minary flow peculiar to the first stage becomes
blended with the changes which follow heart failure, the
second stage ; until ultimately all trace of the first stage is
lost, and the urinary flow assumes the features which charac-

326 THE HEART AND ITS DISEASES.

terise heart failure. The urine of the advanced second stage
will give no denial to the peculiarities of the first having pre-
ceded it, and no diagnosis can be formed from it to reject
a previous stage of primary renal disease affecting the
heart.

The old granular casts found alongside the new exuda-
tion casts will often testify most unmistakably to the fact
of a first stage having preceded the condition then present,
even if the history be doubtful. The two conditions of first
and second stages become blended until the peculiarities of
the first are totally lost and merged in those of the second
stage. These gradually achieved alterations in the renal
secretion, characterising changes in the disease itself, and
the grafting of the symptoms of the second stage on those
of the first, are well and lucidly described by Sir William
Jenner in the Lancet, 1865.

The pathological changes which follow chronic renal
disease are well given in these two tables, taken from Rosen-
stein's "Diseases of the Kidney" (2nd edition, 1870). The
one is a large collection made by Frerichs, and the other a
smaller collection, from Rosenstein's own experience. The
various pathological changes which result from renal disease,
Tirsemic blood, and cardiac failure, are also found to have
other afiections associated with them ; which may possibly
enough be mere coincidences, but certainly do create a sus-
picion of being the result of tissues being fed by a blood
not only poisoned with histolytic products, but in many
cases deprived of albumen by the constant drain through
the kidneys. For many of the cases must have had hearts
no longer hypertrophied, but failing; though no cardiac
condition is recorded but hypertrophy, simple or compli-
cated, with valvular lesions, the writer's scheme not taking
heart failure into consideration.

COMBINED HEART AND KIDNEY DISEASE.

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COMBINED HEART AND KIDNEY DISEASE. 329

A large proportion of the lesions are almost positively
incompatible with the idea of hypertrophy, and must have
been results of failing circulation. As regards the combina-
tion of heart and kidney disease, these tables prove that out
of a total of 406 cases of chronic Bright's disease no less
than 125 died during the stage of hypertrophy, a very serious
proportion ; but there is no record of the heart's condition,
where the same causes which produced the hypertrophy
must have been in action still in the later stages. It is no
more than just to say that of these 406 cases 125 died in the
first stage, according to the division adopted here, and that
of the 281 cases remaining there is no account as to what
was the condition of the heart.

The tables are valuable as indicating the other changes
which follow in various organs, some from the attenuated
condition of the blood, as hydropericardium and hydrothorax,
and others, as pneumonia, pleurisy, pericarditis, &c., from the
absolute presence of poisons in the blood; while the re-
mainder, as tuberculosis, follicular ulceration of the bowels,
possibly resulted as, mere coincidences, or otherwise not
admitting of explanation ; but probably some of them were
the result of the spanaemic blood on which the tissues were
fed. The effect of heart failure on each must not be over-
looked, especially in the cases of serous effusions, oedema
pulmonum, and infarctus. As to the condition of the blood,
and its effect in producing or helping to produce the various
lesions, there is a very probable connection betwixt the two,
and that too of a causational character. In the first place,
as to the blood itself, Christison found the normal specific
gravity of healthy blood to be 1029 and 1031, but in the
subjects of chronic Bright's disease it was as low as 1022.
Frerichs has found it as low as 1022 and 1019, and Rosen-
stein found it as low as 1024. *This diminution is attributed
to the loss of albumen. Blood so altered and attenuated
appears to pass more readily through the walls of the capil-
laries than healthy blood, even without stagnation in the
circulation to aid.

As to the positive contamination of the blood by urinary
excreta non-eliminated, Picard found the proportion of urea

330 THE HEART AND ITS DISEASES.

in healthy normal blood to be '016 per cent., but in diffuse
nephritis it reached '070 and 'OS^G per cent. In the experi-
ments upon animals of extirpation of the kidneys, ligature
of the ureters or blood-vessels, the amount of the various
nitrogenised products of histolysis were found to be in-
creased. This accounts for the inflammatory attacks of the
serous membranes or lungs found in these tables ; while the
positive increase in waste-products and the diminution in
albumen in the blood account for the other affections from
imperfect nutrition. The tables indicate almost to a glance
the various intercurrent affections which follow in the wake
of chronic kidney (and heart) disease, and which commonly
cut off the patient, who is in an already weakened condition.
They will also better enable the reader to understand the
diagnosis and prognosis of the latter stages of Bright's
disease than any amount of other written description possibly
could. We have, in short, the objective ^nd subjective
symptoms of heart failure engrafted on the symptoms of
chronic renal disease described in the first part of this
chapter. The changes in symptomatology entailed by this
have also been alluded to in this section, and each individual
case must explain itself and its symptoms, for to go over all
again now would be a needless repetition or recapitulation.

The progress and termination of these cases is as un-
pleasant a subject for contemplation as medicine furnishes,
for sudden death alone is to be hoped for. Without it, the
progress is steadily downward with the vicious circle ever
widening, and new miseries added to the load, which the
patient has abeady found to be wearily intolerable. Difficult
respiration, utter exhaustion, with sleep even more horrible
than waking, with terrifying dreams taking the place of
waking horrors ; the prospect is utterly unrelieved by a single
ray of hope other than speedy dissolution, by sudden death,
or intercurrent inflammation. While the future contains no
hope, retrospection is embittered by the long list of troubles
endured, of miseries survived. The long vista, which the
patient's memory furnishes to him of what he has existed
through and suffered, since first disease in a depurating
organ led to chemical changes, entailing mechanical results

COMBINED HEART AND KIDNEY DISEASE. 3^1

in their turn, is merely an avenue of tortures, ' steadily in-
creasing as time rolls ; the first ones nearly imperceptible in,
the distance, the immediate ones looming large and near.
The gradual oncome of new additions is often extended over
a period of many years, each new addition marking an epoch,
on entering into another stage worse than the one preceding
it, until the past condition, deemed bad enough at the time,
is looked back to almost with a feeling of envy; and its
troubles would be thankfully accepted in lieu of the present
ones, were such retrograde movement practicable. The con-
dition differs but in degree from Dante's Hell, or the sketches
of future punishment in monkish writings, where as soon as
habitude has rendered one condition of misery somewhat
less intolerable to the damned, another is supposited more
fearful still, with the additional scourge of novelty. The
patients themselves give utterance to this, often saying,
' " this new ailment frightens me so ; for I had got accustomed
to the old one." The brain, fed with blood robbed of its
albumen and poisoned with urine salts, and even that but
sparingly supplied to it by a failing heart and rigid arteries,
and oppressed by venous congestion, falters, and its manifes-
tations become imperfect ; the mind no longer preserves its
accustomed tone; the will is sapped, and the intellect is
enfeebled and becomes childish ; no longer capable of en-
gaging itself on other matters, the attention becomes centred
on the physical condition alone ; the world shrinks to the
dimensions of the sick room, and the patient gradually
passes away from the world and its interests ; and when, at
last, all is over, the sensation is rather of trouble removed,
of rehef .experienced, than of loss sustained.

Treatme7it. — The foregoing description of the pathological
changes and their symptoms will have prepared the reader
for the announcement that the treatment of this condition is
far from a simple matter. At first it is not so difficult, but,
as the case progresses, the gradual involving of some pre-
viously unaffected organ and the addition of a new evil, the
gradual worsening generally; with the various compensatory
actions, each a subject for congratulation, if not excessive,
but easily becoming a source of great danger, present a

332 THE HEART AND ITS DISEASES.

problem not to be solved lightly, and often taxing to the
utmost the physician's skill and resources. For the treat-
ment becomes in time nearly as complex as the disease, and
the remote consequences of our measures must be taken into
consideration, and possible contingencies set against imme-
diate relief to be obtained On the first recognition of the
disease, there are two great considerations and lines of treat-
ment to be adopted. 1. To preserve the purity of the blood
itself; and 2, to guide the various morbid steps so as to
secure a maximum of compensation, and a minimum of
danger resulting therefrom.

To preserve the Purity of the Blood. — This is a matter of
great moment, and there are two opposite conditions to be
fulfilled, viz., to prevent accumulation of waste on one hand,
and to avert anaemia on the other. We will consider the
prevention of waste first. We know that an exclusively
nitrogenised diet increases the amount of urea and uric acid,
and, of course, these passed through the earlier stages of
creatine, creatinine, &c. This accumulation of waste must
be obviated by exact diet, and the amount as well as
quantity must be laid down. Any excess of nitrogenised
food would add to that condition called " ureemic." In speak-
ing of this condition, Dr. Bristowe says, in his Croonian
Lectures on Disease and its Medical Treatment, 1872, " I
may add that it would seem theoretically, and I think that
it is, of the utmost importance, in treating ursemic cases, to
take measures to check the formation of m'ca in the system ;
and that to this end the diet should be carefully regulated,
and not be allowed in quantity to exceed the actual require-
ments of the system." This is the first point to be attended
to, namely, to secure, as far as possible, a nice adjustment
betwixt the needs of the system, its powers of elimination,
and the amount and quantity of food consumed. Some
systems assimilate a much greater proportion of the food
taken than others do ; this must be allowed for, and an
analysis of the mine and a pair of scales for the food will
scarcely cover the necessities of the case. Even the effect
of a large consumption of hydrocarbons in arresting the
oxidation of azotised matters must not be lost sight of here.

COMBINED HEART AND KIDNEY DISEASE. 333

Then there is the second half of this matter, the securing as
complete depuration as is possible. Potash, lithia, and the
waters of Carlsbad or Vichy, and biphosphate of soda ac-
cording to Ritter von SchrofF, the Professor of Materia
Medica at Vienna, will affect the accumulation of uric acid,
and Dr. Roberts of Manchester, speaks in favour of citrate of
potash, and with every reason, in my experience. The effect
of sub-acid wines in checking the elimination of uric acid is
undeniable ; the advertisements of wine-merchants to the
contrary notwithstanding.

Iodide of potassium is a good adjunct often, and colchi-
cum, buchu, juniper, apparently act by increasing the flow
through the nutrient vessels, and the elimination of urine
solids. Arsenic, as Fowler's solution, may often be added to
potash advantageously, especially where the skin is inactive.
Mercury should be avoided from the known intolerance of it
in chronic renal disease. Laxatives,, and general attention
to the bowels are important ; and baths and a good action
on the skin are clearly indicated. Fresh air and exercise are
good, and aid in oxidising the waste products lingering in
their decomposition, and reduce the necessity for rendering
uric acid, or, as it must exist in the alkaline blood, in union
with some base, its insoluble compounds, soluble by potash
or lithia. In administering alkalies, it must be borne in
mind to give them when the stomach is alkaline and empty,
and not with food, or after it, when the stomach is acid ;
except in those cases of acid gouty dyspepsia, where the
excess of acid may be advantageously neutralised. The use
of the alkaline solvents of uric acid must be continuous in
small doses to meet the continuous formation of the acid
itself; and not in intermittent large doses, unless in
paroxysms or exacerbations, when alkaline laxatives are indi-
cated. The bottle of granular citrate of potash on the
dressing table, always at hand, for a tumblerful of water and
a teaspoonful of the salt, on first getting out of bed, or
waking in the morning, and again when commencing to
dress for dinner, is a very good and palatable means of
checking the accumulation of uric acid, and, of course, its
consequential results. This is even better than potash- water

334 ^ THE HEART AND ITS DISEASES.

with or without gin, though that is a therapeutic measure
not to be sneered at„ Potash has a decided tendency to act
on the skin, much more indeed than commonly thought, and
is thus doubly useful.

In other cases there is a decided tendency towards
anaemia. This effect is probably due to the presence of the
excreta in excess, amounting to a blood poison, an action
wliich it shares with malarial poison, syphilis, lead, &c.
There is a decided tendency in these blood poisons to
anaemia and consequent neuralgiae, and the treatment must
not only contain remedies more or less specific in each case,
but also the administration of iron and other haematics. Iron
and quinine in combination with strychnine are often of great
service. What effect they exercise over these arterioles,
here hypertrophied, is not yet known, but they seem to dilate
the unchanged minute vessels of the cerebro-spinal system
at least. Iron is especially desirable as aiding in the forma-
tion of red corpuscles, which are diminished here (Rosen-
stein), in company with other conditions of blood-poisoning.
It is often best given after food, and is then digested with
the food, m the shape of drops, pill, or powder. This effect
is much aided by some easily assimilable fat, as cod-liver oil,
and this combination is very useful in many cases where the
tendency is to anaemia. Why, it is difficult to say; but
chronic kidney disease in Germany has always conveyed to
the writer the very strong impression of assuming an anaemic
type rather than a gouty one, the reverse being, rather, true
in England, even Avith the patients of a public Institution.
Women are unquestionably more liable to put on the ansemic
than the gouty type, and the same may be said of the younger
subjects of this chronic affection. Whether it has anything
to do with the morbid process and its progress in the kidney,
or not, cannot be settled dogmatically either way. The
small granidar kidney is apparently less associated with loss
of albumen by the urine than other forms of disease. All
idea of affecting the progress of the disease in the kidneys
by anti-inflammatory agents cannot be seriously entertained
in the present state of our knowledge, and parenchymatous
inflammations are all very heedless of antiphlogistics. The

COMBINED HEART AND KIDNEY DISEASE. 335

prevention of further disease by tlie avoidance of accumula-
tions of histolytic products, and especially that form in
which the imperfect oxidation is most liable to be persistent,
namely uric acid, must be avoided ; as there does exist some
ground for the suspecting of uric acid of acting as a tissue-
irritant, much like alcohol. Debauches are obviously to be
avoided, and those results of internal congestion of the
viscera from general contraction of the dermal capillaries in-
duced by exposure to cold or draughts, must also be
studiously avoided; for the subjects of chronic Bright's
disease are as susceptible to atmospheric changes as a ther-
mometer or barometer. This extreme susceptibility is insisted
on by all writers on renal disease, and the patient must be
clothed with flannel or silk next the skin, or submit to the
awkward consequences of neglect. They should ever have
a top-coat when stepping out of doors, and imitate the
Austrians, who are very particular about that point, if not
remarkable for attention to other matters of hygiene.

We will now consider more particularly the effects on
the circulation, and the means by which this effect may be
minimised. The first step was vaso-motor spasm, by the effect
on the vaso-motor centre according to Ludwig and Traube,
and the production of hypertrophy of the muscular tunics of
the arterioles, as shown by Johnson and others.

Now it is very obvious that this effect produced by re-
tained tissue-waste circulating in excess must be almost
constant to a greater or less extent ; and that there will be
times of less impurity than others.

The effect of this arteriole spasm is to check waste, it is
quite true, and thus prevent the blood from excessive poison-
ing by reducing the waste to the power of the kidneys. This
conservative action, however, is followed by results on the
left ventricle, and, according to Traube, before any very long
time elapses. It is obvious that the first step in treatment
consists of reducing the impurity to a normal minimum, as
far as possible, by the means mentioned above. A paroxysm
of disturbed renal innervation leads to excess of water and
diminution of salts in the urinc^ There is then an exacer-

* This view of the antagonism betwixt renal flow and amount of soUds

336 THE HEART AND ITS DISEASES.

bation of symptoms, as may readily be conceived ; we have
now a precisely similar train of events from the cause being
present in excess. Catharsis, or profuse diaphoresis by hot-
au' bath, or otherwise, are indicated. During this vaso-motor
spasm we find very often palpitation, as an evidence of heart
taxation. The obstruction to the flow of the blood in the
arterial system tends to prevent the complete contraction of
the left ventricle, and this imperfect emptying leads to dila-
tation. But very commonly, according to even the imperfect
tables (imperfect in this question of effect upon the heart at
least, for probably in the other cases the hypertrophy had
yielded to dilatation, or dilatation had always existed), the
impression of distension excites, though the vaso-inhibitory
nerves, a freer circulation through the coronary vessels, and
this leads to hypertrophy, which resists the distension, and
also enables the heart to perfectly contract.

Dilatation in the heart is a very serious matter here, as
any imperfection in the heart's power would lead to venous
congestion, and then we would have an effect upon the kid-
neys produced therefrom, and still further imperfect depura-
tion. It is obvious, then, that in the treatment of this
condition we must rely strongly on agents which increase
ventricular contraction, of which first stands digitaHs, and
after it belladonna, caffeine, squill, &c. Especially in the
paroxysm must digitalis be used when an additional obstruc-
tion (spasm) is added to the permanent condition (hyper-
trophied arterioles). It is true that digitalis does affect the
arterioles, or capillaries, for Hughes Bennett, Strieker, and
others, think the capillaries contractile, probably as part of
the vaso-motor system, which is affected by it in increasing
the contractions of the heart itself; but still its effect upon
the heart is most important, and the arteriole effect must be
met by depurating tlie blood, as thoroughly as is possible.
No fear of the effects upon the arterioles must deter us from

receives a singular corroboration from Traube, Niemeyer, and others. They
point out the small bulk of urine and high specific gravity in amyloid kidney as
a diagnostic sign, distinguishing it from chronic Bright's disease. In amyloid
disease the glomeruli are most affected, and the tubes comparatively normal, and
the diseased glomeruli obstruct the flow in the convolute vessels, and direct the
blood rather to the nutrient branches.

COMBINED HEART AND KIDNEY DISEASE. 337

seeing the dire results which, will ensue from dilatation of
the ventricular chamber, with all the train of evils which
result therefrom. The combination of digitalis here with
potash, colchicum, and buchu, is of great service ; and even
the combination without digitalis will often afiect palpita-
tion, thus occurring, better than will digitalis, without the
other agents, which assist so markedly in producing an
increase of solids in the urine. There seems some reason
for supposing that agents which produce increased elimina-
tion of urine solids, do so by virtue of some effect over
the innervation of the kidney, z.e., they probably produce
dilatation of the nutrient branches of the renal artery. Some
experiments are much needed here to show the antagonism
betwixt water elimination and urine solids : it is obvious
enough that if such an effect is produced on the nutrient
vessels by attracting a larger portion of blood from the renal
artery, the pressure in the convolute branches must be
lowered. At least we already know enough to be conscious
of the relief which follows then- administration in this condi-
tion. One great difficulty to be surmounted in the treatment
of chronic renal . disease is the constant tendency for the
urine excreta to assume the form of uric acid, which is very
persistent. This arises probably from the impaired action of
the kidneys, which no longer convert the earlier products of
retrograde tissue metamorphosis into urea, a readily soluble
salt passing readily out by the kidneys. Injections of urea
into the blood have not produced ursemic head symptoms,
and the chemical results of an exacerbation are, in all proba-
bility, imperfect conversion of the earlier products into ui'ea
or even uric acid. For these earlier products are by far the
most fatal to life, and most quickly fatal if we compare the
results of ligature of the ureters with extirpation of the
kidneys •; and their conversion into uric acid even is a gain,
for it lessens the immediate danger, if it does ensure struc-
tural changes in the future. In the treatment of uraemia
acute catharsis is our chief hope, and diaphoresis is a great
adjunct ; the Germans approve of cold to the head, but on
what hypothesis I have been unable to ascertain. B. W.
Richardson in his essay on ursemic coma (Asclepiad) gives a

z

338 THE HEART AND ITS DISEASES.

case of uraemic coma simulating apoplexy wliicli must not
be omitted ; for it is most instructive as well as well told.

General venesection is positively of service, in relieving
the convulsions at least, and reducing the symptoms. How
it is achieved is not yet to be explained. The uraemic con-
vulsion and coma may to some extent be regarded as a per-
oxidation, as a useful action, for Rosenstein states, " The
temperature is, so I have found, distinctly raised during the
uraemic attack, more during the convulsions, but also during
the coma," p. 152. That it is a form of peroxidation of a
very alarming and too frequently fatal character, is only too
well established.

Compensatory Actions. — This now brings us to that divi-
sion of treatment which more especially belongs to the plan
of treatment of the acute attacks in other organs, which so
frequently occur during the course of chronic kidney disease.
These are frequently compensatory actions, as diarrhoea,
vomiting, acute inflammatory attacks, &c. They are often
preceded by certain peculiar symptons supposed to indicate
acute congestion of the kidney. These consist of lumbar
pain, weight over the loins, malaise, scanty urine, often ap-
proaching almost complete suppression, and albumen or
blood itself in the urine. Then comes on a pretty smart
action in some other part, very often acute diarrhoea. Now
it is very obvious that here we have a compensatory over-
action, and not a morbid process to deal with; though it is
not to be questioned that the action may become a source of
danger to life, indeed these patients are not uncommonly cut
off by these intercurrent attacks.

But it is very certain that a restoratioji of the action of
the kidney is the most important point in the treatment.

Thus cupping, wet or dry, over the loins, or hot poultices
kept on continuously, and night and morning faced with
mustard, hot-air baths, where practicable, and some non-
irritating diuretic as potus imperialis, or .potash and buchu
may be given. On the restoration of the renal flow, the
diarrhoea will usually subside spontaneously.

All opiate remedies are unsuited to this condition, and the
combination of opium with vegetable astringents is calcu-

COMBINED HEART AND KIDNEY DISEASE. 339

lated to arrest that recovery within the kidney, and restora-
tion of its secretion, which we are so anxious to secure.
When the diarrhoea is becoming itself serious, and assuming
an attitude which makes it a source of danger to Hfe, and
some treatment of it is absolutely called for, a combination
of potash nitrate, pernitrate of iron, and calumba has ap-
peared to me, in practice, to be a good remedial agent against
the diarrhoea, and with a minimum of action on the kidney.
When the renal flow is established, and the diarrhoea per-
sists, more powerful astringents may be indicated; but it
must not be forgotten that opium, like mercury, is unsuited
to chronic renal disease, which seems to endow the patient
with great intolerance of these famous members of the
pharmacopoeia.

Vomiting hero is somewhat difficult to treat, in conse-
quence of the remedies being rejected by it. It is regarded
as a serious indication, usually only occurring in grave con-
ditions. It may be met by cathartic injections per rectum,
and the hot air bath and local applications to the loins.
Dr. Charlton, of Newcastle, says that in uraemic vomiting
nothing is so effective in checking it as carbolic acid in
small doses largely diluted. This may sometimes be indi-
cated from the severity of the vomiting, but the restoration
of the natural secretion is certainly the first indication.

Intercurrent Inflammatory Attacks. — When these occur in
an organ scarcely to be regarded as an eliminating organ, as
in the serous membranes, even then due regard to the cause
will be of great service, and cathartics, local applications to
the loins, and mild diuretics will be useful. How the lungs
stand, and how far pneumonia can be regarded as an elimi-
nant action of the lung tissue, may not be readily settled.
Still, when pneumonia is dependent on a poisoned condi-
tion of the blood, it is better to treat the blood than the
pneumonia, and one case, made a very vivid impression
on me, where pneumonia fright side) came on in an old
friend, who had had more or less constant haematuria for
thu'ty years, and whose urine at the time looked very like
blood ; but he asserted it was better than usual, and so con-
firmed my impression of the attack being ura^mic. Potash,

z 2

340 THE HEART AND ITS DISEASES.

juniper, and buchn constituted a very rapid and satisfac-
tory curative treatment, and the patient, who had been
troubled by a teasing cough, as a symptom of the lung
affection, gave his opinion very confidently to the effect that
it was " the best cough mixture he had ever taken." These
inflammatory affections are better left alone than rashly
treated, and there is little room for doubt that such cases
have often been appealed to as brilliant successes by the ad-
vocates of an expectant treatment, the believers in an alkaline
treatment of inflammations, and other practitioners, denomi-
nated irregular. The writer cannot shake off the impression
that the foundations of the success of the alkaline treatment
of acute inflammations are planted on these ursemic acute
affections. Each affection occurring as an acute intercurrent
ailment in the subject of chronic Bright's disease, must be
specially investigated as to how far it resembles similar
affections in healthy persons, and to be treated accordingly ;
or to be due to the condition of the blood. If the affection
is recurrent, or even if the patient be subject to other affec-
tions, and have repeated attacks of illness, it creates a
suspicion of the nature of the malady and of its connection
with chronic renal disease, even if such disease has not
hitherto been suspected.

Albuminuria. — In many cases of chronic renal disease the
patient is subject to recurrent losses of albumen, on a very
large scale, and suflicient to impoverish the blood very
markedly. Here the administration of tannin in large doses,
or gallic acid, has been advocated, and the loss met by eggs
and other albuminous articles of diet. This loss of albumen
is more apt to occur in the anasmic forms than in the gouty
type of renal disease. This anasmic type, as said before, is
very common in Germany, Still Niemeyer is not in favour
of large doses of tannin. Frerichs advocates its use, how-
ever, and has a favomite form in pill with the watery extract
of aloes. A. Hill Hassell and others in England advocate
tannin and gallic acid, while Beale and others advocate pre-
parations of iron, and especially the perchloride. The latter
is perhaps, on the whole, the better plan of the two, as the
iron is a more decided haematic than tannin. The effect of

COMBINED HEART AND KIDNEY DISEASE. '^41

anasmia in weakening the heart must not be overlooked in
its treatment. Before leaving the treatment of the first
stage, it may be desirable to mention that the attacks of
apoplexy occurring in this stage do not often admit of relief,
and are very commonly fatal. Free venesection and catharsis
are here indicated.

Sleeplessness, — Sometimes the patient will seek medical
aid for the sleeplessness of this condition. Opium in all
forms is most unsuitable, even in the form of the popular
subcutaneous injection. It is not well borne in these chronic
renal conditions, often not only failing to produce sleep, but
even occasioning greater wakefulness, with great mental dis-
turbance. It certainly affects the kidneys, whether by
arresting the action in the epithelium cells of the uriniferous
tubules, or how, is not yet ascertained. Opium and morphia
are often resorted to for this very action, of arresting the
elimination of urine solids, in the condition of azoturia, or
excessive excretion of urea. Some of the other " seven
sisters of sleep," as hyoscyamus, belladonna, tincture of hop,
lactucine, &c., may be used to combat this sleeplessness, or
the noYvT popular remedy, hydrate of chloral.

Treatment of the 2nd Stage, — This is eminently unsatisfac-
tory and is ever palliative rather than curative. It is the treat-
ment of failing heart modified by renal complication ; that
is, it is a form of heart failure which goes very readily down-
wards in spite of all treatment, when once the heart failure
is marked. When the hypertrophy is being cut down by
fatty degeneration, by molecular necrosis within the muscular
primitive bundles, all treatment of the heart by digitalis,
iron, &c., is devoid of any lasting value. There may be a
fan' amount of muscular structure remaining sound, and
thus giving out good first sound, and palpitating vigorously
at times, especially on exertion, but the condition is not a
remediable one. It is not mere failure of the heart, it is
failure before a blood current, obstructed by hypertrophied
arterioles ; and spasm induced by blood still less depurated
from the effect of venous congestion of the kidneys, and
accumulation of waste products in the blood, even more than
before ; of failure combined with a rigid non-elastic aorta,

342 THE HEART AND ITS DISEASES.

with its feeble recoil met by spasm in the arterioles of the
coronary circulation ; is it any matter for surprise, then, that
drugs are ineffective here ? It would be matter for much
greater surprise if they were effective under such circum-
stances : and those who find digitahs in some cases appa-
rently inert, are seriously recommended to go over the case
again more thoroughly, to ascertain, beyond doubt, how
far the failure lies in a diagnosis itself imperfect, and not
taking in all the factors, and not in any inertness in the
agent.

These cases go rapidly downwards, and are little, if at
all, amenable to treatment, other than action on the various
depurating organs ; relief of attacks of dyspnoea by hot
applications to dilate the minute vessels of the skin, and
even, at times, by venesection when the danger is imminent.
Free purgation, by relieving the congestion in the valveless
portal circulation, and this affects the renal veins, will not
often only give immediate relief, but even does good for some
little time after, by the improvement in the circulation within
the kidney, thus admitting of the blood being brought more
freely in contact with the depurating organs, as well as
increased elimination of water.

In one point, however, the dropsy of this combined con-
dition differs from that of pure heart disease, and that is its
being better ' relieved by incisions or punctures. There are
some points of difference in its production, and the thinning
of the blood modifies the stagnation, and dropsy will occur
in a less feeble condition of the heart than when renal disease
is wanting. The loss of albumen and positive presence of
salts, and tissue waste in excess, appear to cause it to pass
more readily into the tissues It gives relief to the circula-
tion often, and patients recover and go out again to resume
their occupations in a manner different to pure cardiac dropsy.
In fact the earlier attacks may fairly be considered renal
dropsy, little, if at all, modified by the heart affection.

But when the heart failure becomes pronounced, this renal
character becomes merged into the dropsy more especially
cardiac, and though it never is so strictly an advance from
the most dependant parts upwards, and is found in the upper

COMBINED HEART AND KIDNEY DISEASE. 343

extremities and face, more than in true cardiac dropsy, the
condition becomes practically cardiac.

The treatment depends on the condition: if the heart's
action be good, hot-air baths, diaphoretics, and cathartics,
especially such as pulv. scam, co., gamboge with bitartrate
of potash, elaterium, &c., are indicated ; and incisions may
be useful. Digitalis, squill, &c., so useful as diuretics in heart
failure, are not indicated here, though very serviceable after
the heart's action, tells us it is failing in power, and unequal
to maintaining fair arterial tension.

In all complications the presence of renal products, and
more especially the most permanent form of uric acid or
urates, must not be overlooked in the treatment, and potash
assumes a much more important position in our armentaria
than it does in simple heart failure. Thus the dyspepsia is
gouty as well as catarrhal ; so also the bronchitis ; the skin is
much more liable to affections, and especially gouty eczema.
Alkaline lotions and the internal administration of alkalies is
indicated. The waters of Carlsbad, Vichy, Vals, Seltzer,
Kissengen, and other alkaline-salt waters are here indicated,
and are easily procured now in bottle ; or potash water, and
potus imperialis.

The other alkaline chalybeate waters, as Pullna, Pyrmont,
Schwallbach, &c., and the bitter waters of Fredericshall,
rather belong to the first stage, but are often in place even
later on. The free dilution of the alkalies administered in
combination with other agents, from the medicine bottle, is
advisable, and then they resemble in effectiveness more the
natural waters.

The general treatment of this stage must be conducted
according to the rules laid down in the Chapter on the
Treatment of Diseases of the Heart, with the modifications
indicated above, and such others as the necessities of each
individual case seem to indicate.

Kidney Disease the Result, and not the Cause, of
Heart Disease. — Early in the observations made as to the
connection of heart and kidney disease, one set of authprities
maintained that the kidney disease stood to the heart disease
as a consequence, and not a cause. But in time this view

344 THE HEART AND ITS DISEASES.

got, to a great extent, lost sight of, and for some time past
kidnej disease has rather been regarded as the cause of
heart disease, than as the result of it. Having considered
kidney disease in relation to heart disease as a cause, and
also the effect of heart failure back again upon the kid-
neys, the writer now proposes to consider kidney disease
solely as a result of heart disease. When from any cause,
but usually acute injury to a valve, as from rheumatic
fever, &c., the heart is injured, so that its function is imper-
fectly carried out, there results a certain amount of venous
congestion, from the blood lying more on the venous than
the arterial side. There follows from this plethora abdomi-
nalis, or venous fulness of the abdomen; this venous stagna-
tion being most felt in the valveless portal circulation.

The venous fulness is most apparent in the divisions of
the lower vena cava in heart failure, and the veins of the
lower extremities being protected by valves, this venous
stagnation affects most the portal veins, not being so pro-
tected. Thus we find that the various viscera, as liver,
spleen, hitestinal canal, kidneys, and generative organs, are
subjected to an impeded circulation from this venous con-
gestion. The same impeded circulation also affects the lungs
and cerebro-spinal system, as we saw in Chapter IV. This
impeded circulation leads to a peculitir form of structural
change in the viscera. The higher tissues, or higher histo-
logical forms, are not affected, but the connective-tissue, or
basement-membrane, that is the lowest histological form out
of which the higher textures are developed, becomes affected
by this vascular repletion. This connective-tissue is found,
more or less sparingly, in every viscus, and lies betwixt the
higher tissues, occupying the interspaces and forming a sort
of packing. When there is venous congestion, or venous
hypergemia, there is a proliferation of cells in this low histo-
logical form. The organs become somewhat larger, denser,
and on section a glutinous bloody fluid exudes ; in time, a
disthict cirrhosis results, and we get cirrhosed Hver (nutmeg-
liver) from the shrinking of tlie new connective-tissue growth,
and a similar condition of spleen, the organs being hard,
firm, and contracted. There is in organs permitting of it,, an

COMBINED HEART AND KIDNEY DISEASE. 345

accumulation of albuminous fluid, as ascites, hydrocele,
&c., and from the mucous surface a flow of albuminous fluid.
The kidneys are also involved, and their scanty connective-
tissue becomes the subject of hyperplasia from venous hyper-
semia. The kidneys, after a valvular affection of the heart,
proving quickly fatal, are somewhat enlarged, vascular,
deep-coloured, and injected ; a bloody fluid exudes on section,
and to the touch they feel finer and denser than the norm :
in fact, instead of a mass of vessels and tubules with very
scanty connective-tissue, there is now found a distinct growth
of new connective-tissue. The capsule is still smooth, but
either generally deep reddish, or the surface is chequered
with stellate injection of the venules (stellulse Verheynii), the
cortical substance is thickened, injected in streaks, or of a
greyish red colour ; the cones are hypersemic and darkened,
while the papillae are pale in comparison.

The epithelium cells are coiled up (gewundenen), and the
tubules filled with blood-tube casts, or stained albuminous
masses, occasionally undergoing fatty degeneration. This
account of von Dusch is perfectly corroborated by observa-
tions made by the writer in the Pathological Institute of
Vienna during the past winter ; when the kidneys, along
with the liver and spleen, were found altered by heart disease,
with the certainty of a physical law. When the kidneys
were long afiected by old-standing heart disease, they were
small, hard, the cortical substance small and atrophied, with
the surface granular, and the capsule adherent ; in fact, they
were cirrhosed kidneys.

This interstitial nephritis, for it is a parenchymatous
inflammation according to Virchow, may also be accompanied
by metastatic nephritis from embolism, but usually is simple
and uncomplicated. It arises from venous hyperaemia
exactly as does the same interstitial disease of the liver,
spleen, &c.* This aflection of the kidneys from heart-disease,

* From the accumulations in serous cavities, from venous hypersemia, the
albuminous urine, and albuminous discharge from the bowels, it would seem that
in venous hyperemia there is exudation of liquor sanguinis, either from surfaces
or into tissues ; and that in the tissues the excessive supply of albumen leads to
cell-proliferation in the connective tissue, and this leads ultimately to compres-

346 THE HEART AND ITS DISEASES.

especially valvular failure, but equally from any other cause
leading to venous congestion, has been more recently in-
vestigated by Forster, Oppolzer, Traube, Rosenstein, and von
Dusch.

In 67 cases of granular-atrophy of the kidneys, Forster
found no less than 26 with valvular disease of the heart ; and
came to the conclusion that valve-failure was a cause of
chronic Bright's disease. Oppolzer regarded chronic renal
disease as a consequence of valvular disease. Traube has
held this view strongly, and found the symptoms of this
renal disease, as given from the renal secretion, to be diminu-
tion of bulk (from loss of arterial pressure), and a consequent
concentration of the urine, with deposit of urates on cooling,
the urine more or less albuminous, from " transuded blood-
serum" (transudirt blutserum), and with long, hyaline,
exudation-casts (schlauchformige Cylinder), in fact just what
Frerichs got from ligature of the renal veins. Rosenstein
has taken up a modified position, and regards chronic kidney
disease as sometimes the consequence, and at other times the
cause, of endocardial disease. These different observers all
agree in the view of heart failure, valvular or other, being a
cause of interstitial nephritis ; and this view was taught in
Rokitansky's school. The recognition of the fact that struc-
tural changes in the kidney follow heart failure is an im-
portant matter, not only from a prognostic, but from a thera-
peutic point of view.

When the course of the heart failure has been short, the
changes in the kidney are evidently of recent date, but where
a heart lesion has existed some considerable time, the kidney
disease is of longer standing, and more gradual. An acute
failure, sufficiently marked to cause death in a few months,
causes a general interstitial cell-proliferation in the kidneys ;
but none the less does the process go on in the more chronic
cases of slight valvular affection, not enough to kill, but only
to cripple. Here there is a venous congestion less marked
but enduring, the same process only extending over a longer
period of time. Thus in these cases the original valve lesion
is met by compensatory muscular growth, and the compen-

sion of the other structures, first from simple pressure, and later on bj compression
from the contracting or shrinking of the new tissue.

COMBINED HEART AND KIDNEY DISEASE. 347

sation is long maintained; but still no compensation is
entirely perfect, and so the impediment in the circulation *
slowly and insidiously lays the foundation of a new obstruct-
ing process by the installation of chronic renal disease. Then
comes the circle of mischief detailed in the first part of the
chapter, the vaso-motor spasm, with hypertrophy of the
arterioles, and obstruction to the blood stream ; this, in
addition to the old valve lesion^ brings about dilatation and
heart failure ; and the valvular lesion, years after its inaugura-
tion and apparent compensation, leads ultimately to heart
failure round by the kidneys. This effect of venous stagna-
tion on the kidneys, of structural changes induced by venous
hyperaemia, points out how very important it is to secure
good acting power in the heart, not only for its own main-
tenance, but also to avoid, and delay as long as possible, the
venous congestion which inaugurates the renal changes.
The importance of securing good ventricular contraction, of
good circulation, is demonstrated unanswerably, and the
therapeutic importance of that list of agents which induce
increased ventricular contraction is enhanced. We have seen
that heart failure is the- turning point in the progress and
prognosis of chronic renal disease, when a cause of heart
disease ; and now we see what a disaster impeded circulation
from heart failure is in ultimately overtaxing the organ
already enfeebled. The clinical importance of avoiding
venous congestion from heart failure, of improving the action
of the heart by aiding in securing compensatory hypertrophy,
of delaying, as long as may be, the venous congestion, no
longer to be averted, is demonstrated only too clearly. In
heart disease the appearance of albumen in the urine, with
exudation-casts, marks the inauguration of a secondary
process which will work evil, and that, too, in no long time.
In a little while a chronic Bright's disease is firmly established
with all its consequences, and it may not be possible always
to determine which lesion came first in the order of time ;
they are there together, and the combined condition of heart
and kidney disease is complicated by a lesion in the heart
itself, whose effect upon the case and its prognosis is the
reverse of desirable.

The valve lesion may have inaugurated the renal disease,

348 THE HEART AND ITS DISEASES.

or the renal disease may have led to the valve lesion, fur
endocarditis is a common consequential complication of
chronic Bright's disease ; at any rate they exist together, and
the valve lesion is accompanied by granular tube-casts, &c.,
and the symptoms of chronic renal disease. In the same way
kidneys are found, which, while presenting the evidences
of general recent interstitial inflammation, carry on their
surface pits, or scars, old depressions indicating a primary
renal disease, which has led to changes ultimately entailing
heart failure, and the implantation of recent disease on the
old primary affection. The mutual effect of heart disease
on kidney disease,, and the causational relationship of chronic
Bright's disease to heart failure, are now sufficiently
thoroughly established, and admit no longer of doubt as to
their pathological connection; and the sooner an equally
complete recognition of this connection is entered in our
therapeutical indications the better.

If w^e do ]5)ossess agents which increase ventricular con-
traction, and thus maintain a more even balance betwixt the
amount of blood in the arterial and venous system, with-
out allowing that balance to found by capillary congestion
(venous hypersemia), it is time that the importance of that
action be fully recognized. And whatever vestiges of old
theories of accumulative actions, and of dangers arising from
an administration of the drug in the wrong condition, may
linger ; it is quite time that these declining ideas be either
laid quietly in the tomb or their absolute accuracy be demon-
strated, and rules founded thereon and framed thereby, be
laid down as to the action of digitalis and other agents
increasing ventricular contraction. For as to the benefits
to accrue from their use, and the dangers to be positively
averted or delayed by their administration, there is no ques-
tion. Let, then, the shadowy dangers, said to arise during
the use of digitalis, be fairly set against these benefits and a
balance struck. That the morbid downward process can
only be delayed, in the great majority of cases, by treat-
ment it is true ; and that increased ventricular action will
ensure arterial distension and atheroma is equally certain;
but all treatment is the substituting of a lesser for a greater
evil ; and with the positive danger of venous congestion and

COMBINED HEART AND KIDNEY DISEASE. 349

consequences looming large and distinct, we cannot wait in
our action or delay our treatment, except for very valid
reasons shown why it should not be proceeded with.

The falling off in the bulk of urine is ever an indication of
an unpleasant prognostic character, as indicating decrease in
arterial tension; while the positive presence of albumen and
exudation-casts in the urine are signs, whose import is only
too unmistakable, in the course of a heart lesion. The heart,
already somewhat incompetent, will soon have another very
serious addition to its troubles in the shape of arteriole
obstruction ; and if any treatment can restore, however par-
tially, for a time the balance betwixt the amount of blood in
the arterial and venous system, there is no time to be lost in
applying it.

This chapter has grown somewhat lengthy, but the im-
portance of the subject must excuse that. For, in the
present age, when heart disease is increasing, induced by
the rate at which we live ; when the great frequency of
chronic renal disease is being understood ; and finally,
when pathologists are demonstrating how these diseases act
and react ; the practical physician cannot overlook the im-
portance of the connection nor its therapeutical indications.
We have seen how a slight affection of the kidney will dis-
turb the balance betwixt the material to be excreted and the
power to so excrete it ; how this will lead to ultimate degenera-
tion in the circulation, and secondary renal disease therefrom,
ere it is ultimately fatal. We have also seen how a valvular
lesion of the heart, by disturbing the balance of the circula-
tion, may lead to renal implication, and from that produce
disease which admits no longer of compensation; how the
first compensation by muscular growth is in time destroyed
by another call upon it. We have seen enough of the mutual
relationship of heart and kidney disease to see that there can
be no complete comprehension of the one, possible even, with-
out a fair understanding of the other, and any defects in this
chapter must have allowances made for them ; while the
writer trusts that this attempt to sytematically arrange this
connection, with the results arising therefrom, will lead to
more perfect and elaborate working out of the subject by
other writers.

350 THE HEART AND ITS DISEASES.

CHAPTER XIV.

Diseases of the Great Vessels near the heart.

(This chapter is absolutely necessary, as many affections
of the vessels in its neighbourhood are very similar to dis-
ease of the heart itself in symptoms, signs, and course. It is
only in so far that these affections are considered here ; and
aneurisms of the arch and descending theoractic aorta, toge-
ther with abdominal aneurisms, are not part of the writer's
plan. Aneurisms of the ascending aorta, or of such portion
only as is covered by pericardium, simulate heart-disease
itself closely, while, when in other parts, they have other
signs or symptoms which point to their aneurismal cha-
racter).

,The Atheromatous Process — Aortic Dilatation-
Aneurism— Symptoms— Signs — Prognosis— Treatment.

Atheroma is the name in common use in England to signify
disease and degeneration of the arteries, but its synonyms
endarteriitis deformans, seu nodosa, or arterio-sclerosis are
also in common use elsewhere. The disease is not due to
any acute inflammatory action in the arterial coats, a dis-
ease whose existence is disputed, but is one of the interstitial
parenchymatous inflammations of Virchow, and consists of a
proliferation of connective-tissue elements under the tunica
intima. The first appearance of atheroma consists in localised
patches of these elements forming a papule under the intima
and often placed at points subjected to great tension ; indeed
that is its favourite seat when localized. At other times this
proliferation goes on in the sub-end arterial tissue in a more
general manner, and gives a roughness and variegation to the
artery when seen opened, the arteries appearing as if small
rice-like bodies were inserted beneath the tunica intima.

DISEASES OF THE GREAT VESSELS.. 351

The new growth itself consists of masses of young connective-
tissue, with small, round, and spindle-shaped cells, and when
in localized masses mucin is also found, giving the mass
the appearance of slime. When the affection is more dif-
fused the small masses are firm, solid, and resistant to
pressure.

This chronic inflammatory process becomes modified in
two dii'ections during its progress, each a degeneration;
these two are calcification and fatty degeneration.

Calcification, or petrifaction, the latter often the more
applicable term, consists of the deposit of earthy salts in these
masses of connective-tissue. Sometimes the mass is some-
what crumbling and mortar-like, but at other times, and
especially near the aortic valves, the process is rather to be
denominated petrifaction, a stony feel being given to the
touch. This process depends on the deposit, or infiltration,
of lime salts into the connective-tissue corpuscles, and is a
rude attempt at ossification, the term used by older writers.
This will proceed, when in patches, until a stony plate is
formed, which may ultimately become loose, and wash off
mto the circulation. When the affection is more general, the
arteries become converted into rigid brittle tubes, often so
impairing the circulation through them as to lead to gangrene
of the extremities, especially the lower.

Fatty Degeneration, — At other times these collections of
young tissue undergo fatty degeneration, become softened
and yellow, consisting of fatty granulations, or oil-drops
even, with cholesterine scales, and morsels of connective-
tissue, forming what is called a puree of pease. This mass
may become washed off into the circulation, and form embo-
Hsms, or become sufficiently disintegrated to form merely
capillary embolisms, or even to a great extent be lost in the
circulation. This mass has usually eroded to some extent
the arterial wall beneath it, and leaves an ulcer on the artery
(Usur). This commonly leads to aneurism, either simple or
dissecting.

Atheroma, and especially when it is general and tends to
calcification, may become general, and extend from the aorta
down into the coronary vessels, up into the vessels within

352 THE HEART AND ITS DISEASES.

the encephalon, — these, indeed, are commonly affected, and
in fact over the whole arterial system to its termination in
muscular arterioles. The veins, and especially the large
veins, are liable to become atheromatous ; but venous athe-
roma is never so marked as is the disease in the arteries.

Causes. — The exciting cause of atheroma is usually a
cachexia, and it is found along with chronic Bright's disease^
gout, syphilis, cancer, and chronic alcoholism. It is connected
with such chronic affections as are regarded rather as blood
diseases. The endarterium has no blood-vessels of its own,
but derives its nutrition from the blood-current rushing
through it (Rindfleisch). Thus, whenever the blood is altered
in its properties, this alteration leads to tissue-growth, the
lowest form, that of basement membrane, being most readily
affected. It seems that the lower the form of tissue-life,
the more prone it is to take on abnormal growth. Thus
alcohol, gout, and syphilis poisons are tissue-irritants appa-
rently. In syphilis Ave recognise a tendency to form masses
of young connective-tissue in various tissues, muscle, sub-
periosteum, brain, &c., and the process of forming gummata
in the heart may proceed up into the scanty muscular tissue
of the aorta^ lyii^g beneath the intima. But unquestionably
the great exciting cause of atheroma is strain. Thus we find
it at points of most tension, at branches or bifurcations, at
the coronary orifice ; Ave find it in the pulmonary vessels be-
hind mitral disease, and in the vense cavse after tricuspid
regurgitation ; as also in veins Avhen an artery opens into
them. We find it in the pulmonary valves folloAving on the
accentuation of the second sound brought out by strain. We
find it in the aortic valves in hammer-men, and Ave find it,
above all things, in chronic renal disease. The connection
of atheroma Avith gout is Avell established. Rindfleisch, in
section 215, states that gout and endarteriitis have a common
setiology, and are, therefore, commonly found together. How
this connection exists Ave saAv in the last chapter ; how im-
perfectly depurated blood in renal disease led to vaso-motor
Bpasm, hypertrophy of the muscular arterioles and the heart,
and excessive distension of the elastic tubes connecting
them. Strain is the great exciting cause of this parench^)-

DISEASES OF THE GREAT VESSELS. 353

matous inflammation called atheroma. Chronic disease of
the lining membrane of the circulation is too intimately
associated with strain to admit of doubt as to the existence
of association, and it is impossible to refer their co-existence
to mere coincidence. •

Dilatation of the Aorta (Erweiterung). — This affection is
allied pathologically to aneurism, but differs from even fusi-
form aneurism, in being rather a generalised than a localised
affection. The aorta becoming generally atheromatous is
thickened, its surface roughened, and its elasticity impaired.
The first effect of atheroma is to diminish the cahbre of the
vessels by its own thickness, obviously enough. But as the
arterial coat becomes altered dilatation takes place. The
heart is usually hypertrophied, and the distending force of
the blood-current considerable, the degenerate artery is dis-
tended forcibly, and its recoil is not quite perfect. Thus in
time with the repeated distension of every systole the calibre-
of the vessel is altered, it becomes generally widened and
dilated. This is especially the case with the upper portion
of the aorta, and especially on the outer surface of the aortic
curves.

Sympto7ns and Signs. — This affection is not of a demon-
strative character, and is rather detected by the physician than
a cause of suffering to the patient. There is a decided
increase in percussion dulness across the aorta at the second
right costo-sternal articulation : there is also a harsh systolic
murmur, especially when free from aortic regurgitation ; this
is due to the roughened surface; and the blood-current becomes
audible over it, as a murmur. There is commonly, too, a
delay in the pulse of the extremities. But the most certain
diagnostic sign is to insert the finger in the sternal notch, at
the same time telling the patient to thrust his head forward.
Then, the aortic heave becomes distinctly perceptible, and the
murmur may be felt as a thrill. This is not likely to be con-
founded with an aortic aneurism.

This condition is usually accompanied by cardiac hyper-
trophy ; but sooner or later the impaired aortic recoil leads to
imperfect coronary circulation and to degeneration of the
heart walls.

2 A

354 THE HEART AND ITS DISEASES.

The affection is very commonly found along with, aortic
valvulitis, both resulting from the same cause. The affection
is also usually found either iri the subjects of chronic Bright's
disease, or in " strikers," &c. It is one of the outcomes of
arterial strain, and as such is rarely found alone.

Prognosis. — There is no very favourable prognosis here,
and the most that can be hoped for is, a tardy downhill
course. The tendency is to death from cardiac failure, due
to tissue degeneration. The condition is rarely confined to
the aortic arch, though most marked there, and in this
generally atheromatous condition, cardiac failure may be
anticipated by some intercurrent disease carrying off the
patient.

Aneurism. Varieties of Aneurisms. — Aneurism is a more
localised affection, and is due either to localised disease caus-
ing the wall to yield, the old true aneurism, or possessing
all of the arterial coats ; or it may result from an atheromatous
patch undergoing fatty degeneration and disintegration,
forming an ulcer, then it was called a false aneurism, i.e.,
not possessing all the tissues. This aneurism may be simply
bulging, or it may be dissecting, and burrow under the edges
of the ulcer, betwixt the arterial tissues, and ultimately point
and burst at some point at a. comparative distance from the
the ulcer in the inner coat. At other times the aneurism is
more general, and is fusiform or spindle-shaped, or annular,
a bulging all around the aorta ; this last form of aneurism
has been supposed by Rokitansky to take its origin in vaso-
motor paralysis of a portion' of the vessel. The seat of
aneurism may be any part of tlie artery including the
sinuses of Valsalva.

The pathology of aneurism is that of the atheromatous
process wifli some effort, to rupture a weakened spot. This
is not always the case, as in the dissecting aneurism fi'om an
atheromatous ulcer, and in the case of lost vaso-motor con-
tractility. It has been always, up to a recent period, asserted
that aneurism never occurred in an artery unaffected by
pre-existing disease. The occurrence of purely traumatic
aneurism from falls and accidents has of late caused some to
adopt the view of the causation of aneurism by a shock or

DISEASES OF THE GREAT VESSELS. 355

blow over the vessel during its systole, or when fully dis-
tended by ventricular contraction. This view has been
supported by Dr. Clifford Allbutt with his usual able advocacy,
and he holds that when so distended, the brittle inner coat is
easily cracked and an aneurism formed. When once formed,
there is not much question as to its progress ; every systole,
especially under excitement, adds its mite ; for the pressure
of the blood being equal on all parts of the arterial system,
the weakest point will always most readily yield. The
pulsating sac may preserve its roundness, or become nodu-
lated, or pouched, burrowing among the tissues when so
pouched, and advancing by erosion when round. The course
may sometimes be indicated by pressure on some organ ;
there may be difficulty in breathing, from pressure on the
air tubes ; or in swallowing from pressure on the oesophagus ;
or dropsy from pressure on the venye cavse, sometimes the
dropsy being confined to one or other extremity from pres-
sure on one vena cava only. Or a nerve may be compressed,
and the recurrent laryngeal, which curves round the aortic
arch, is especially apt to be compressed, producing hoarse-
ness, aphonia, or the " ringing cough," said to be diagnostic
of aneurism. Or some large arterial branch may be affected,
and the pulsations of two corresponding arteries, as the
radial for instance, be rendered unequal. Pressure on the
ganglionic nerves is supposed to affect the size of the pupil
of the eye, on the same side as the aneurism. Pain, ever
constant in the spine, is suggestive of erosion of the spinal
column by an aneurism, and Walshe lays great and deserved
stress on this point : constant pain in the spine without
apparent cause being ever significant.

Progress and Terminations. — :The progress of a thoracic
aneurism is untoward, and leads to death, variously. Rup-
ture of the sac by a blow may anticipate erosion of the coats ;
dyspnoea may prove fatal ; or the patient die of inanition
from the difficulty in swallowing. Erosion of the spine may
lead to spinal meningitis, and erosion of the sternum to
external haemorrhage. We know little or nothing of the
result of pressure on the thoracic duct. General ill-health,
dropsy, &c., may gradually wear out the patient. Rupture

2 A 2

356 THE HEART AND ITS DISEASES.

may occur into various parts not leading to sudden death ;
when into either mediastinum it is apt to be quickly fatal.
Even erosion of the bronchial wall and haemoptysis has
been followed by arrest of the haemorrhage by a clot, the
haemorrhage not returning for some time, but proving fatal
finally; this was the case with the famous Listen. The
rupture will sometimes take place into the veins, arteries, or
chambers of the heart itself, of which instances have been
collected by Dr. Peacock; by far the largest proportion
burst into the pulmonary artery, amounting to three-sevenths
of the whole collected cases.

Diagnosis. — The diagnosis of an aneimsm, in nearly every
case, depends on the peculiar symptoms of each case, their
grouping, and relation to each other. When deep seated we
can get no aid from inspection, palpation, or percussion,
unless it be deep seated, comparative dulness, a not very
trustworthy sign. There is usually a distinct bellows mur-
mur (Blasebalggerausch), which may at times obscure the
normal sounds of the heart, and at other times leave them
distinct ; in this latter case the diagnosis of aneurism, or of
tumour pressing on an artery, is cleared from any heart
affection producing murmur. This is the only positive sign.
Delayed pulse at the wrist is of some diagnostic aid. The
symptoms derived from pressure will often throw much
light on the scanty positive evidence of the existence of
thoracic aneurism. The following direct expression by
Niemeyer will illustrate the difficulty of diagnosing deep-
seated aneurism: — "As long as the aneurism remains en-
closed within the thorax, without touching its wall, diagnosis
is not assisted by physical examination." When the
aneurism approaches the thoracic wall then it may be seen
pulsating in the inter-costal spaces, or felt by a thrill, the
" fremissement cataire." Its diagnosis is no longer difiicult
when the thoracic parietes are reached. Dr. Peacock says,
" The patients, who are the subjects of anemism of the
ascending portion of the aorta, are most commonly of the
male sex, and at or about the middle or more advanced
period of life. Not unfrequently they have been the subjects
of rheumatism, and have been addicted to spirit-drinking and

DISEASES OF THE GREAT VESSELS. 357

habits of intemperance. Most usually they present the com-
mon cardiac symptoms — dyspnoea, palpitation, and tumultuous
action of the heart, dropsical symptoms, and signs of engorge-
ment of the lungs and parenchymatous viscera. These
symptoms sometimes commence insidiously, and advance
gradually ; in other cases they occur somewhat suddenly,
and as the result of some injury or strain." The diagnosis
of thoracic aneurism, as long as deep seated in the thorax, is
to be founded on the especial symptoms of each case, and
not by any rules which can be laid down.

Prognosis. — So rarely does a thoracic aneurism end in
recovery, that the prognosis is necessarily very unfavourable.
Life may be maintained for some time by proper care, but it
is rather with that object, viz., retarding the progress of the
case, than in the hope of cure, that treatment is adopted.
Still as success is possible, even though highly improbable,
it should be borne in mind as a possibility.

Treatment — The treatment of aneurisms must be con-
ducted on the principle of avoiding what would add to the
size and volume of the aneurism, or tend to rupture it. Thus
great quiet of body and mind is absolutely indicated, avoid-
ance of excitement, exertion, or effort must be insisted upon.
No straining at stool must be permitted, and the bowels
must be kept regularly open, and the patient must be warned
against straining, and told, if the bowels do not act easily, to
wait some time and make another attempt, anythhig in pre-
ference to strainiQg. All causes which would hasten the
pulse,' as alcohol, &c., must be carefully avoided.

For the indications in the treatment of aneurism are not
precisely the same as in the treatment of disease of the heart
itself; there ventricular contraction must be maintained, here
every increase, either in number or power, of the heart's
contraction adds to the mischief already inaugurated. A few
beats more or less each minute makes up a grave sum total
in the day of the number of times this sac has been dis-
tended, and the pulse may be well kept as slow as well as
low as possible. This has been attempted by the adminis-
tration of digitalis until the symptoms of poisoning by it —
small, feeble, slow, irregular pulse, from abnormal contracted

358 THE HEART AND ITS DISEASES.

condition of the ventricle — are induced. Another plan is to
lower the ventricular contractions by the administration of
aconite ; a preferable plan to the digitalis poisoning.

The old plan of treatment of Albertini and Valsalva by
bleeding and starvation has not now many advocates. A
plan of treatment has recently been adopted, especially by
the Dublin School, with very encouraging success. It con-
sists in a rigorous adhesion to the recumbent posture, to
reduce to a minimum the effects of pulsation, the effect of
the horizontal posture in reducing the number of pulse-beats
per minute is well known : in addition to this purely physio-
logical treatment, iodide of potassium is administered in full
and large doses. The results of this treatment are suffi-
ciently encouraging to make further trial of it desirable ; for
if the success be limited, the prognosis of the disease must
be taken into consideration. Astringents administered in-
ternally, with the hope of coagulating the contents of the
aneurismal sac, are not now much resorted to, and .the same
may be said about opium. In the severe pain often caused
by an aneurism opium, the subcutaneous injection of mor-
phine, or other narcotic, are very useful. Here the pain is due
to pressure on a nerve, and to relieve it there are only two
feasible plans, to remove the pressure, not very practicable
here, or to deaden the susceptibility of the nerve centres, the
only effective plan.

When the aneurism has reached the ichest wall, other"
plans of treatment are feasible. To relieve pain and violent
pulsation in the sac, the Germans are fond of ice, pounded,
and applied in an india-rubber bag. To attain the same end
lotions of lead and opium have been resorted to, not without
effect. To attempt coagulation of the contents of the sac,
galvano-puncture has been used, Tliis method was first
used by Petrequin, and has since been tried by many. It is
rather adapted to hospitals than general practice, and the
treatment is yet rather experimental than established. When
the aneurism has fairly eroded its way through the chest
wall, and formed a pulsating tumour on the surface of the
chest, a cover of leather, moulded to the tumour, sheet-lead,
or other material^ may be appHed to reduce to the risk of

DISEASES OF THE GREAT VESSELS. 359

blow or other accident. When so protruding these aneurisms
have been known to be opened by the lancet_, chiefly by
irregular practitioners, and it is somewhat satisfactory to
know that these ill directed surgical efforts were not imme-
diately fatal. This was due to layers of fibrin under the sac
wall ; and when the sac and skin are ultimately opened by
ulceration, sometimes life is prolonged by a clot plugging up
the orifice, just as in Listen's case a clot in the bronchial
orifice prolonged life for some weeks.

The no less interesting subject of aneurisms of the de-
scending aorta, both thoracic and abdominal, cannot be'
taken up here, as not directly belonging to the subject under
consideration.

The veins near the heart are rarely themselves affected,
except by atheroma, which neither leads to rupture nor
aneurism. Tumours, simple, malignant, or aneurismal often,
however, press on one or both venae cavse. The dropsy,
confined to the district of the great venous trunk pressed
upon, will often indicate the nature of the cause of that
localised dropsy. When general, however, it cannot be dis-
tinguished from dropsy arising from tricuspid failure.

360 THE HEART AND ITS DISEASES.

CHAPTER XV.

Malformations of the Heart.

The heart is liable to various malformations, which often
interfere seriously with the performance of its function. At
one time the prominent symptom, cyanosis, was apphed as a
designation covering each malformation. More exact re-
search has demonstrated that these malformations arise in four
ways, viz. : — 1. Imperfect evolution. 2. Peculiarities -of the
foetal circulation remaining. 3. Diseases dming foetal life.
4. Mere anomalies.

1. Imperfect Evolution, — This may amount to total absence
01 the heart, a matter of little moment to physicians. Then
the heart may remain of batrachian type, and consist of oiily
one ventricular chamber, due to imperfection in the septum
ventriculorum. The imperfection may vary from a small
perforation to a complete loss of the septum. At other
times the arterial stem remains uncleft, and the aorta and
pulmonary artery are in one vessel. At other times, again,
the stem is cleft, and the relative position of aorta and pul-
monary artery transposed.

2. Peculiarities of the Foetal Circulation remaining. — The
foramen ovale may remain patent, and where there is also
tricuspid stenosis the foramen ovale rarely closes. The
Ductus Botalli may remain, and a communication betwixt
the right ventricle and the descending aorta may exist
permanently.

3. Diseases during Foetal Life. — During foetal life the heart
is liable to endocarditis, and various malformations arise
therefrom. As during foetal life the circulation is mainly
carried on by the right side of the heart, diseases then occur-
ring are commonly found, if not always, in the right side.
Indeed, primary disease of the right side of the heart is very

MALFORMATIONS OF THE HEART. 361

rare in extra-uterine existence; but when failure in the
mitral valve has thrown the stress of the systemic circulation,
to some extent, at least, upon the right side, it again becomes
liable to disease. The most common results of foetal endo-
carditis are stenosis of the ostia, pulmonic, tricuspid, or rarely
aortic or mitral. This often takes place in the conus arte-
riosus, and not absolutely at the arterial orifices. In the
auriculo-ventricular ostia the ring round the ostia is affected.
Stenosis may affect the blood-vessels, and in the Pathological
Museum of Vienna there are two cases, one of aortic stenosis
below (immediately) the Ductus BotalK, the other stenosis of
the lower vena cava, close to the heart. In both cases great
vessels were found in connection with the internal mammary
and the vessels of the dorsal muscles. It has been recently
asserted that imperfection in the septum ventriculorum may
arise from disease in foetal life. Here it is supposed that a
syphilitic gumma has existed in the septum, and the part, thus
weakened, has given way and opened the ventricles into each
other.

4. Mere Anomalies. — These may be found, as four semi-
lunar valves for three, three flaps in the mitral, &c., but the
most interesting is transposition of the viscera. Here the
heart, along with the spleen, is on the right side, and the
liver and ascending colon on the left. The position of the
stomach is reversed, and the pylorus points left, and the car-
diac orifice to the right. The lungs are transposed also. It
is not recorded whether these persons were left-handed in
life, or not. In the Vienna Museum there is an excellent
specimen of this, and a second is being prepared.

These malformations may afiect the heart's function most
gravely, or not at all, according as to which is present, and
to what extent in some of them. In some cases post-mortem
examination alone detects them ; in others they incapacitate
the sufferer from an independent extra-uterine existence.

With neither of these, as physicians, can we have much
to do, but in the numerous less extreme cases we may be
consulted. The chief question is as to how far the children
80 afflicted are likely to live. Some short history of these
unfortunates may not be out of place. As children, they are

362 THE HEART AND ITS DISEASES.

blue with dark lips, and readily induced dyspnoea. They are"
usually of somewhat lowered temperature, little able to stand
exposure to cold, and readily affected by changes of tempera-
ture. The periphery is liable to undergo changes, and the
nose and lips are blue, while the fingers and toes are dark
coloured and clubbed. The tips thicken, and the fingers
especially are club4ike. These sufferers may dwindle on to
puberty which they can rarely accomphsh, they seem too
cold blooded to take on puberty with its accompanying
passions ; they are reptilian like, and the batrachian heart
seems to involve a sort of batrachian existence. The mental
manifestations are feeble, and the mind and body remaia
childish, even when the growth exceeds that of childhood.
In a case which occurred to my friend, Dr. Elliot, of Carlisle
(see Proceedings of the Royal Medico-Chirurgical Society,
1868), the young man had reached manhood, and was being
educated for a missionary, when he died. The cyanotic
signs first showed themselves when three months old, and
yet he lived to the age of nineteen years and eight months.
His heart was univentricular and batrachian, the septum
ventriculorum being totally wanting. The subjects of con-
genital cyanosis are liable to suffer from venous congestion
and its consequences, especially plethora abdominalis, and
usually evidences of insterstitial growth of connective tissue
are found freely in liver, spleen, and kidneys. Death may
occur from the direct consequences of these visceral changes,
or from some intercurrent disease, which the sufferers with
weak hearts, and altered viscera therefrom, are incapable of
successfully withstandiag.

" Mere imperfection of the septum does not cause cyan-
osis, but is a harmless anomaly, which gives no evidence
of its existence during life " (Niemeyer). And the possibility
of such congenital imperfection must not be forgottpn,
when strange or anomalous heart affections present them-
selves.

Diagnosis. — The diagnosis of congenital malformation is
usually not difficult, but the diagnosis of what imperfection
you have to deal with is usually impossible.

The splendid collection of cases, with histories, in Dr.

MALFORMATIONS OF THE HEART. 363

Peacock's book must be appealed to for further information,
not only as to diagnosis, but for other information on this
subject generally.

Prognosis, — This is in accordance with the history given
above, but observable congenital malformation, not being
mere transposition, carries with it ever but a poor prognosis.
A necessarily short life is surrounded with more than ordinary
perils from intercurrent affections.

Treatment. — There can be no treatment more than which
is merely palliative, and such measures may be used in each
particular case as the necessities of the case may seem to
indicate, or the good sense of the practitioner suggest. One
thing is certain, these human reptiles must ever be warmly
clad and protected against atmospheric variations of tem-
perature.

364 THE HEART AND ITS DISEASES.

CHAPTER XVI.

CoNCLUDiNa Chapter — Elements of Prognosis in Heart

Disease.

General Elements of Prognosis — Embolism — Heart Dis-
ease IN Thoracic Deformity — Heart Disease from
Chronic Affections of the Respiratory Organs —
Heart Disease and Phthisis in Young Persons — Val-
vular Disease and Phthisis — Clubbed Fingers— Redu-
plication OF Heart Sounds — Persistency of Murmurs.
— Conclusion.

The necessity for placing the remarks on prognosis in the
concluding chapter is obvious, for all the different forms of
disease must be considered, and the distinctive points touched
upon, before any arrangement of the different factors of prog-
nosis could be attempted. ^ ^

Prognosis, of course, is the opinion of the medical man as
to the probable course and duration of a disease, and can
obviously exercise no control pver the disease itself; unless
that prognosis have been rashly and unwarily given to the
patient in a manner to seriously shock or alarm him. There
is no doubt that, in the case mentioned by Stokes, where, on
hearing a cardiac murmur, a medical man announced to
the patient, " Ah I I have just heard your death-knell," this
unwarrantable speech had a very unfortunate effect upon the
patient. Neither is it proper that the patient should be
frankly told that " You will die suddenly some day !" as in a
case well known to myself, and where the outspoken doctor
has some years ago gone to his rest, and very suddenly too,
while the patient lives on without any evidence of organic
disease about him, hale and active, but his life simply
poisoned by that rash opinion ; and had he really had dis-

ELEMENTS OF PROGNOSIS. 365

ease of the heart, as was supposed by the frank medical man,
it is very probable the effect of this outspoken prognosis
would have gone far to verify it.

Treatment, too, will often tend to verify a hopeless prog-
nosis, possibly not warranted by the facts of the case. But
putting aside these auxiliaries towards verifying a prognosis,
there are certain signs and symptoms which will guide us in
forming a prognosis. It will, perhaps, be best to give the
mdications for a gloomy prognosis, and, of course, the absence
of them will always go far to warrant a hopeful prognosis ;
and to commence with the indications given by the heart
itself.

Heart's Force. — The loss of impulsive energy in the heart,
the impaired vigour of the ventricular contractions, is ever an
unpleasant indication, and more decidedly so when the first
sound is low or lost. The tendencv to become broader, and
the percussion dulness wider, is significant that the chambers
are suffering from dilatation, and this is the more significant
if previous hypertrophy has existed ; for it suggests the pro-
bability that the hypertrophy is yielding, and a dilating
process inaugurated, by degeneration of the muscular struc-
ture of the heart itself. This is often found to be the case
where there is atheroma of the arteries and co-existing
Bright's disease.

Rythm. — Taken in conjunction witji loss of force the loss
of rythm is suggestive ; but loss of rythm alone may be a
mere nervous disturbance. When, along with increasing
loss of force, the heart's action becomes unrythmical, the
condition is a grave one. Palpitation induced by slight
effort is suggestive as indicating a tendency in the chambers
to become distended or engorged. More serious is irregu-
larity in the pulse on slight effort, whether combined with
palpitation or not; but when with an irregular, or worse
still, intermittent pulse syncope is induced by effort, then the
prognosis is very bad. Intermittency, not nervous, but
orgaiiic, is ever a serious indication, and indicates commonly
structural disease of the heart-walls, while the existence of a
number of rapid, small beats before the pause is usually
indicative of dilatation.

366 THE HEART AND ITS DISEASES.

Valve Failure. — Whenever a vavular lesion co-exists with
evidences of muscular failure, and the presence of objective
symptoms, the prognosis is worse, cceteris paribus, than
when no such lesion exists. The implantation of a new
cause of failure in the circulation on an old one, which has
already taxed the recuperative powers of the system in
establishing compensatory forces, is ever of grave significance
prognostically. We know nothing of valve failure resulting
from muscular failure only, and without disease in the valves
themselves, as it is never so produced; Rokitan sky saying
that the valves stretch along with the muscular walls and
the ostia, and Oppolzer and Kiirschner stating that such
valve failure is anatomically impossible ; though Wilkinson
King could produce tricuspid leakage in the heart when
removed from the body. But of the opposite condition of
muscular failure coming on after valvular failure has existed
some time ; we have unfortunately too many opportunities of
seeing it. As to the prognosis to be arrived at from the
seat of the valvular lesion, Dr. Peacock says (on the Prognosis
in cases of Valvular Disease of the Heart) " The order in
which these conditions should be placed, as indicating their
relative danger, beginning with the more serious affections,
would, therefore, be as follows :

Aortic Regurgitant Disease.
Mitral Regurgitant Disease.
Mitral Obstructive Disease.
Aortic Obstructive Disease.

The comparative rarity of serious affections of the right side
of the heart, and their being usually combined with other
defects in the conformation of the organ, make it difficult to
estimate the relative danger which attends them, as com-
pared with disease of the left valves." Dr. Peacock puts the
positions correctly here, unless some doubt may be felt as to
the comparative danger to life in the affections of the mitral.
Combinations of valvular lesions, and the fliilure of one
leading to disease of another behind it, especially must be
regarded as ever of grave prognostic import, and the
occurence of tricuspid insufficiency after mitral failure Tnarks

ELEMENTS OF PROGNOSIS. 367

an epoch on the case, and a date from which the downward
process will be rapid.

General Power. — Impairment of general power, and the
rapid oncome of dyspnoea, and the various objective symp-
toms of heart failure on slight exertion, are indications of
bad omen. Often the patient will have spontaneously and
instinctively, but unconsciously, assumed a very steady slow
walk with great watchfulness against shocks, or any neces-
sity for exertion ; and there is a gait almost pathognomonic of
heart disease, especially of structural decay. Along with
this will commonly be found the evidences of mental impair-
ment from cerebral anaemia. There is no aberration of intel-
lect, it is simply amentia from the impaired supply of arterial
blood. The patient's gait and walk are accompanied by
imperfect power of thinking, and a want of self-confidence,
and when these general indications are found along with the
other indications of heart failure, the prognosis, as to life, is
hopeless ; and even as to time is very gloomy.

Loss of Arterial Tension. — This is ever of great moment
in forming a prognosis, and the best external evidence of this
loss, the diminution in the bulk of urine, is ever significant.
This may be somewhat obscured by pre-existing kidney
disease, but the falling ofi" is still distinct enough, when fail-
ing power in the heart is lessening the pressure on the
glomei'uli of the malpighian bodies. The prognostic import
of faUing off in bulk in the urine is well known among the
laity of the north of England, and is regarded as a symptom
scarcely less significant than the appearance of dropsy. Thus
popular opinion and the investigations of Traube coincide.
The efiect of increase in the bulk of urine after the adminis-
tration of any agent, as digitalis for instance, is always hailed
as a good sign. This is not a difficult subject to understand
when we remember the clear connection betwixt arterial
tension and the elimination of water on the one hand, and
betwixt arterial tension and ventricular contraction on the
other. Any improvement in the action of the organ, or
pump, for its action is mechanical, wliich lifts the blood from
the venous side over into the arteries, is at once felt in the
increase of arterial tension.

368 THE HEART AND ITS DISEASES.

Venous Congestion. — It is obvious that venous congestion
and arterial tension are proportioned to each other inversely*
increase in one lessens the other, when the capillaries transmit
the blood more quickly to the veins, then the heart passes it
again into the arteries. We get the veins too full and the
arteries too empty. The effect of such agents as digitalis
in contracting the capillaries, may aid in mcreasing arterial
tension, by not letting the blood flow out so readily by them,
as well as by increasing ventricular contraction. The loss of
arterial tension, as shown by diminution of bulk of urine, is
accompanied by venous congestion, as shown in the engorge-
ment of the viscera, called plethora abdominalis ; and when
this has proceeded to the point of albuminuria, and the pro-
duction of exudation tube-casts, the condition is serious
indeed. Here the impaired circulation in the nutritive vessels
of the kidney leads to imperfect elimination of urine salts,
though the small bulk of albuminous urine may be of high
sp. gr., and laden with urates ; and this imperfect elimination
leads to vaso-motor spasm, Avhich further taxes the already
enfeebled heart.* The presence of albuminuria and new
exudation-casts is of the gravest import.

Dropsy. — Though dropsy may come and go again, its
prognostic value is unmistakable ; and when, with the
symptoms of heart failure, oedema sets in over the arch of
the foot, and round the ankle, and though beaten off for a
time, returns again in greater force, each time more persistent,
until, at last, firmly established, the indication is very serious.
Here even the venous valves of the lower limbs are unequal
to preventing venous engorgement, and water is effusing
into the areolar tissue. The venous twigs are too full, and
the watery constituents of the blood are escaping through
the coats of the venules, indicating a debility in the centre
of the circulation, of the gravest significance. When the
venous dilatation has rendered the jugular valves incompetent,
and the mere undulation or wave from the backward flow

* This is not a contradiction to the possihle good of digitahs, whoso action
on tlie ventricle is also accompanied by action on the arterioles and capil-
laries. Tlie peripheral circulation has been already dilated from the effect of
distension of the heart acting on the vaso-inhibitorj nerve.

ELEMENTS OF PROGNOSIS. 369

on closing the tricuspid is converted into a pulsation, it is
evident that the ventricular contraction is no longer entirely
shut off from backward flow ; and that there is a leak in the
tricuspid, which is exposing the veins behind to the force of
ventricular contraction, dilating them and rendering their
valves incompetent, and thus* increasing venous congestion ;
while the amount flowing back at every systole is so much
less for the left ventricle to pass forward into the arteries.

These are the elements of prognosis considered generally,
but each individual case will have certain peculiarities of its
own, which the practitioner must take into his calculation.
Thus necessity for exertion, for labour, makes the prognosis
ever worse for the working population than the wealthier
classes. The presence of any other old standing disease
adds to the gravity. Something, too, depends on family
history. In some families death is apt to be sudden, while
in others the patient endures to the '' bitter end." The mind
and force of character affect the prognosis ; and the mind,
which can best maintain its balance, endows the owner with
some degree of protection ; while some minds never recover
the shock of the most careful and guarded prognosis. Cir-
cumstances likely to excite the patient are very unfavourable ;
the excitement of war times, of important law suits, of expo-
sure to annoyance or irritation are all bad. The great John
Hunter felt his life to be in the hand of any one who should
excite his choleric temper, and the result justified his prog-
nosis. The liability to some intercurrent disease must not be
overlooked ; and an occupation involving exposure, and thus
liability to cold or inflammatory affections, ever lessens the
chance of life. In some cases there is great risk from rupture
of 4ne of the vessels within the encephalon, and the occur-
rence of cerebral haemorrhage. While again there is another
danger, which defies our calculations often, and though
occurring without heart disease, is still more liable then to
occur, viz., the formation of vegetations in the altered valves,
or thrombosis in the ventricular chamber, and the occurrence
of embolism.

The importance of diseases occuriing from solid matters
finding their way into the circulation, and ultimately lodging

2 b

370 THE HEART AND ITS DISEASES.

somewhere and arresting tlie circulation, has only been
recognised in recent years. These soHd bodies form variously,
but one end is common to all, viz., a floating in the blood-
current until the calibre of the vessels no longer admits of
further passage, and an embolism is formed. The embolon
itself may arise, and commonly enough does, from the settling
of fibrine on the surfaces of the valves; deposits on the
valves, not vegetations sprmging from the valves, and these
are very liable to form during endocarditis, when the two
great factors, a fibrinous condition of blood and an altered
condition of endocardium are found together. Clots may
form among the columnee carneae and become dislodged.
They locate themselves in different places according as
accident in the blood-current determines. The straightest
course is the most favourite one, and embolism is most
commonly found in the left middle cerebral artery, causing
the marked right side paralysis with aphasia so charac-
teristic of an embolon. This sudden arrest of circulation
fells the patient as with a stroke, and thus the cerebral affec-
tion differs in its onset from cerebral haemorrhage. After
passing the aortic arch, the clot* may lodge in the branches of
the coeliac axis, and lodge in the spleen, liver, or' superior
mesenteric. Small clots are very apt to pass into the renal
artery and lodge in the kidney. Large clots may plug the
iliac arteries or their branches. Small particles may cause
mere capillary embolism. The consequences of an embolon
are summed up by Cohuheim* as of four orders. The plug
may remain quiet and without consequences ; or gangrene
and necrosis may follow ; or infarction behind it ; or forma-
tion of abscess.f To permit of the first there must be a
possibility of collateral circulation being established.

The clot may lodge in the coronary arteries themselves.
At other times the embolism may arise from the pulmonic
circulation, and be the result of tissue-necrosis from a clot

* Untcrsuchungen liber die Embolisclien Proccsse. Berlin, 1872.

+ Another consequence of embolism must not be overlooked, and that is
certain material can, when lodged, excite a similar cell-growth to itself in the
new locality ; thus cancer-cells from scirrhus of tlie pylorus excite secondary
cancerous growths in the liver, when they have found their way into the portal
circulation and been arrested in the livpr.

ELEMENTS OF PROGNOSIS. 371

which took its origin in phlebitis. EmboHsm is very com-
monly found under other circumstances than those of heart
disease, but is sufficiently associated with heart disease to be
considered here. In guarding a prognosis, embolism, like
cerebral haemorrhage in hypertrophy, must not be lost sight
of as a possibility.

Relation of Heart Disease to Phthisis in the Young. — In a
few cases of caseous pneumonia in the young, the writer has
noticed at the same time a dilated condition of the heart. In
all these cases the prognosis was bad, and treatment was
very ineffectual. The cases have not been sufficiently
numerous to warrant any pathological inferences as to the
connection of the two affections ; but the opinion formed so
far, inclines to regard the right ventricle as being more
affected than the left; but the absence of a post-mortem
examination, in the cases, leaves this subject very much in
the dark. All that can be said on it with any certainty is
the fact that the cases did very badly, and that in combined
cases of phthisis and dilated heart the prognosis is very
bad.

Heart Disease ivith Thoraic Deformity. — Rokitansky first
pointed out how enlargement of the heart is commonly found
in thoracic deformity arising from caries of the dorsal ver-
tebrse. The altered relations of the thoracic viscera obstruct
the flow of blood and evoke hypertrophy, sooner or later
yielding, however, when the general health becomes infirm.
In several cases cardiac dropsy in young people^ with
thoracic deformity, has been brought under the writer's
notice, and in all the cases did badly.

In the several cases this breaking down occurred at a
period when puberty would ordinarily be developed ; but the
cases were not numerous enough to furnish data sufficient for
any positive expression. The dropsy was true cardiac dropsy,
commencing from below upwards, and accompanied by ob-
jective symptoms of heart failm-e.

Heart Disease and Chronic Affections of the Respiratory
Organs. — Affections of the respiratory organs frequently
occasion diseases of the right side of the heart. Thus
caseous pneumonia, we have seen, will lead to right-side

2 B 2

372 THE HEART AND ITS DISEASES.

failui'e. The affections most markedly connected with right-
side faihu'e are emphysema,, interstitial pneumonia (cirrhosis
of the lung), chronic bronchitis, and pleuritic effusion. These
affections are also concomitants of heart failure, and in many
cases it is impossible to ascertain which came first in the
order of time : prognostically it is not of much moment, as
their concomitance is grave enough. But pathologically it
is interesting to trace the connection, and the connection of
the affections mth heart failure, as sequelae, is traced in
Chapter IV; the opposite condition of their standing to
heart disease in the relation of causes, deserves a few words.
In many cases it is not very difficult to trace the order of the
combination, while in others the affection of the respiratory
organs is under care when the heart affection shows itself.
The effect of emphysema in the compression of some vessels
and in the dilatation and elongation of others, and thus
obstructing the pulmonic circulation ; of pleuritic effusion in
general compression of the lung ; of chronic bronchitis in
arresting the respiratory changes, and thus leading to im-
paired blood flow^ it is not difficult to comprehend.

Thus, in treating these affections it is always desirable to
bear in mind the probability of right-side heart failure, and
the occurrence of such failure warrants at once a grave
prognosis. In such cases the course is apt to be rapid, and
that it should be so is intelligible enough. The right ven-
tricle is yielding and the obstruction remains as bad as ever,
or even now aggravated by the failure in the right ventricle,
and a smaller bulk of blood is passed over to the left ven-
tricle ; aortic distension and recoil are impaired, there is
general impairment in the supply of arterial blood, and this,
too, affects the heart itself. At the same time the distended
right ventricle is acting more rapidly, because never emptied,
the period of rest is much diminished, and the heart wall
Boon becomes degenerate and fails entirely. The tendency
of affections of the respiratory organs to induce heart failure
by early loss of compensatory growth, is thus intelligible
enough. In other cases the right ventricle hypertrophies
more perfectly and efficiently, and life is longer maintained ;
and in these cases the ultimately fatal morbid process is

ELEMENTS OF PROGNOSIS. 373

somewhat different. The strain on the tricuspid valves in-
duces valvulitis, the valve then becomes incompetent, and
we have the consequences of tricuspid failure to deal with ;
and our aid under such circumstances is not of much avail.
In chronic affections of the respiratory organs the certainty
of right side failure in time, unless the patient be carried off
ere it is induced, must ever render the prognosis very gloomy,
and a prolongation of life by care ; the avoidance of fresh
attacks of disease in the enfeebled respiratory organs, and
proper therapeutic aid, is all that can, at the best, be hoped
for. The evidence of right-side failure having commenced
no longer warrants anything but the most unfavourable
prognosis, even as to time. ^

Chronic Valvular Disease and PhtJiisis. — While disease
of the heart not only predisposes to lung disease of various
forms, but is really followed by certain diseases of the respi-
ratory organs as results, as consequences of itself, a some-
what curious effect has been pointed out by Kokitansky.
He, as a pathologi'St, has noticed the fact that chronic endo-
carditis, or valvular disease, is rarely or never accompanied
by any evidence of tubercle, or caseous pneumonia; that is,
of any recent disease, for traces of such disease having
existed at a time previous to the endocarditis are, of course,
not obliterated by it. This fact of the absence of phthisis in
chronic valvular disease had not entirely escaped Laennec
himself. The curious association of chronic valvular disease
with freedom from phthisis has been supposed by Traube to
be due to the free transudation of blood-serum into the
parenchyma 6f the lung in such valvular failure ; a condition
opposed to the condition favourable to caseous change in new
cell elements which are due to a general deficiency of water
in them.

Traube's hypothesis may not be quite satisfactory, but the
fact, as indicated by Rokitansky, remains the same. On the
other hand Lebert has regarded congenital pulmonary sten-
osis as a predispos'ig causes of phthisis. In five such cases
which came under Dr. Peacock's notice, two had simple
stenosis, and both died of phthisis ; the other three had other
defects in the conformation of the heart, and did not have

374 THE HEART AND ITS DISEASES.

phthisis, and the lungs were much congested, but not tuber-
culous, at the post mortem examination.

Clubbed Fingers. — The peculiar thickening around the
nails of the fingers, and, indeed, in the ends of the fingers
generally, which has been denominated "clubbed fingers,"
was once thought to be pathognomic of congenital malfor-
mation of the heart, or cyanosis. Pollock has regarded it as
sufficiently associated with chronic phthisis as to be to some
extent distinctive. They are found, however, very commonly
in cases of chronic valvular disease, and the thickening seems
to depend on a prohferation of connective tissue elements in
the part, due to blood-stasis, as seen in plethora abdominalis ;
and also to fulness of the free vascular distribution of the
finger ends. The same fulness exists in the lips of young
persons who have chronic valvular disease. The sign indi-
cates most probably venous stagnation, and is thus found in
chronic phthisis only as the result of obstructed pulmonic
circulation and right side heart failure, with its sequel venous
congestion. Its indication is essentially chronicity, and so far
it throws some light on the past ; but its use in aiding to
calculate the future is not yet ascertained.

Though not quite in place, still it is equally difiicult to
see where they could be more appropriately introduced, I
may here allude to two subjects not unconnected with prog-
nosis, but still rather associated with the diagnosis of heart
failure, viz., (1) reduplication of heart sounds, and (2) the
temporary cessation of murmurs. Both, are subjects which
cannot be overlooked, and yet furnish us with no real infor-
mation of practical utility.

1. Reduplication of heart sounds is occasionally heard
very distinctly, and, though rare, is equally unmistakable
when occurring. This phenomenon has had a great deal of
attention paid to it, but its value is yet undetermined.
Bouilland called it " une signe de luxe," sufficiently expres-
sive of his opinion and experience. Nor has the most recent
systematic writer on heart disease expressed himself any
more favourably to its indicative value. '' In its pathological
import and diagnostic significance it is a sign of very little
value" (Flint, p. 327). From the cii'cumstances with which

ELEMENTS OF PROGNOSIS. ' 375

it is associated, it would appear sometimes to indicate a
lagging behind of the contraction of one side of the heart,
from some obstruction offered to the flow of blood from it.
But probably Flint's description is not far from being exactly-
true.

2. Temporary Cessation of Murmurs, — While murmurs are
at times merely temporary in their character, as when due
to anaemia, or spasmodic and irregular action of the musculi
papillares; it is equally certain that valvular disease may
exist without any evidence to auscultation, and that the
murmur arising from it may be at times intermittent. We
are not yet sufficiently acquainted with the temporary cessa-
tion of an organic murmur to say much as to its cause.
Murmurs most commonly intermit at the auriculo-ventricular
orifices, but even an aortic regurgitant murmur, the least
likely of all, will occasionally intermit. When such tem-
porary cessation occurs it is diagnostically troublesome, and
may lead to a difference of opinion betwixt two medical men;
not due in any way to lack of competence, or even to an
active imagination, but simply to the fact that the murmur
was audible at the time when the patient was seen by one,
and inaudible when seen by the other. The chief indication,
indeed, of this temporary cessation of murmurs is its value
in leading us to be charitable to the mental processes of
others. A murmur present when the patient consults a
London physician and inaudible when listened for by a rural
practitioner, might go far to inflict a severe blow to his
reputation ; and more so if again audible in the metropolis.
Even under the best and most favom-able circumstances, in
such a case, the decision would probably rest on a calculation
of probabilities, as to the flitting nature of murmurs versus
the imperfect auscultatory powers of rural practitioners, and
though the balance would descend in favour of the latter, the
first must not be forgotten as a possibility. Another fact
must not be overlooked, and that is the absence of murmurs
in left side valvular disease after the tricuspid valve has
become affected. In two well-marked cases which came
under the writer's notice, most extensive aortic and mitral
stenosis combined were found on post mortem examination,

376 • THE HEART AND ITS DISEASES.

along with tricuspid insufficiency from valvulitis. In the
one a tricuspid murmur was audible over a very hmited area
at the ensiform cartilage, which passed away and was in-
audible for some weeks previous to the patient's decease,
and the left side double stenosis had never produced any
audible evidence of its existence ; in the other a faint diastolic
murmur was heard over the third left costo-sternal articula-
tion (the pulmonary area), but only at one spot, a most
limited space in fact, and from this, and the marked e^ddence
of right side enlargement, the diagnosis of probable pul-
monary regurgitation was ventured in the face of its rarity.
The post mortem examination revealed most extensive
mitral and aortic stenosis, also allowing of regurgitation and
great right side enlargement, hypertrophy with dilatation,
and tricuspid valvulitis. From this it was evident that the
murmur was aortic, and not pulmonary.

The general elements of prognosis must consist of a cer-
tain number of signs and symptoms variously combined, and
rarely all existing together. Too much value must not be
attached to any physical sign, trustworthy as they usually
are, but a large and widely comprehensive view of every
case must be taken. The effect of obstructed circulation is
felt all over the organism, and the impeded working of each
and every part must be taken into consideration. Death may
threaten from heart failure directly in one case, from some
distant consequential complication in another. The heart
disease may be primary, and all else be but results of it, while
in other cases it is itself secondary. The tendency, said to
be on the increase, of a "specialist" to see everything as
takuig its origin in the organ to whose diseases he has
specially given his attention, is not always a subject for a
sneer ; for if, of two men of equal attainments, the one turns
his attention more exclusively to one organ's maladies and
their sequela), while the other's attention is equally spread
over the diseases of the body generally; it is no more than
probable that the . " specialist " can see some things not
always readily apparent to the other ; if it were not so, the
argument would equally apply against a separate^ profession
of medical men. But in the consideration of the various

' ELEMENTS OF PROGNOSIS. 377

consequences which follow any failure in the circulation,
even to the periphery of the system, the recognition of heart
failure and its importance is very necessary. The depriva-
tion of arterial blood and the presence of venous blood
in excess affects every organ and its functional working.
The dependence *of other affections, apparently primary,
or some unrecognised failure of the heart, is more common
than our self-pride as to diagnostic powers would sometimes
admit. Chronic trouble, laid to the charge of a liver whose
working is not quite " what it might be," will be found
often to be due to a failure in the heart hitherto unrecog-
nised. Uterine troubles and renal disease are alike, at times,
the result of impaired circulation. Cerebral disorder, with
corresponding psychical manifestations, is now known to be'
a result of defective supply of arterial blood and of venous
congestion. While it is certainly undesirable to attribute
more to the failure of power in the heart than can be fairly
so attributed, or, in other words, to survey pathological
anatomy from the stand-point of the circulatory centre; a
performance containing withm itself probably the same ele-
ments of failure as the survey of the universe, in astronomy,
from the earth as a stand-point did ; and so compelled all
calculation to be made from an ideal centre for observation
— a process which might be advantageously copied in prac-
tical medicine — it is equally certain that the importance of
the recognition of heart disease and its consequences, and of
the means of relieving it, is not generally fully appreciated.

INDEX.

A.

PAGE

Albuminuria, prognostic value of,
in heart failure . . . . . . 345

Accentuation of second sound . . 21
Amyloid heart . . . . . . 192

Anaemia, cerebral, from heart
failure . . . . . . . . 174

Anaemic murmurs . . . . . . 21

Aneurism of heart. . . . . . 148

of aorta . . . . . . 354

Apoplexy in aortic regurgitation. . 123

■ in chronic Bright's disease . . 320

Arterioles, spasm of, in hysteria . . 257

in Bright's disease . . . . 288

hypertrophied muscular wall

of, in Bright's disease . . . . 289

■ effect of in left ventricle . . 289
Atheroma, cause and pathology of 352
Atrophy of heart . . . . . . 192

Auscultation of heart . . . . 8

Angina pectoris . . . . . . 250

Aortic valvulitis
stenosis
insufficiency
atheroma

aneurism

108
115
120
352
354

B.

Basedow's disease . . . . . . 276

Blood supply of heart itself . . 3
Breast-pang. See Angina Pectoris.
Brain, venous congestion of . . 45
effect on, of defective supply

of arterial blood. . . . . . 174

effect of impure blood on, in

Bright's disease . . . . . . 309

Brown atrophy of heart . . . . 191

c.

Carbonic acid poisoning, symptoms
of 54

Casts in urine, value of . . . . 305

Cheync, symptom of . . . . 54

Chorea, palpitation of . . . . 282

PAGE

Clubbed fingers in heart disease . . 374

Compensatory hypertrophy . . 67

Congestion, general venous . . 44

of portal system . . . . 46

effect of, on kidneys. . . . 48

effect on lungs . . . . 45

Cor bovinum . . . . . . 65

Coronary circulation, peculiarities

in . . . . . . . . . . 3

Cough of heart disease . . . . 130

D.

Degeneration, fatty, of heart

in arterial atheroma . .

Delayed pulse

Diagnosis of aortic and mitral
disease . .

of mitral stenosis and regur-
gitation , .

of left and right side hyper-
trophy

aid to from arterial system. .
aid to, from venous system. .

Digitalis, action of. .

Dilatation of heart

veins in tricuspid regurgita-
tion

Distension of heart, palpitation
sign of . . . . . . . .

cause of hypertrophy

Displacement of heart . . . .

Dreams unpleasant in heart disease

Dyspnoea, cause of, in anasarca . .

inexplicable in Bright's dis-
ease

cardiac (false angina)

151

155

27

119

132

79

26

29

214

77

137

36
57
198
46
53

308
173
146
149

Dittrich, scars of

stenosis (cardiac) of. .

E.

Elimination, vicarious, in renal
disease . . . . . . . . 293

Embolism, when induced . . . . 370

380

INDEX.

Endocarditis, acute

ulcerative

chronic

cause of

antagonism of, to phthisis

F.

Fatty degeneration of heart

causation of

pathology of . .
poisoning, cause of
objectiye symptoms of

arcus senilis in. ,

• cerebral ansemia in

treatment of . .

infiltration of heart . .

PAGE

. 97
, 101
, 103
, 108
373

151
155
152'
160
166
169
174
181
185
360
14

Foramen ovale, patent
Fremissement cataire

G.

General treatment of heart disease 200
Graves' disease. See Basedow's

Disease.
Gummata in adult heart . . . . 192
foetal heart . . . . . . 361

H.

Hsemopericardium
Haemoptysis in heart disease
Heart, evolution of

circulation in. .

mode of action . .

sleep of . . . .

innervation of

248

222

1

2
3

4

7

Heart and kidney disease combined 284
Heart disease, general treatment

of.
Horizontal position when intoler-
able . . • • • •
Hydropericardium. .
Hypersesthesia of heart . .
Hyperplasia
Hypertrophy, causes of . .

symptoms of . ,

■■ signs of . . . . . .

duration of . .

treatment of . .

of left ventricle in Bright's

disease
of right side after

disease . .
Hypertrophy of auricles

of arterioles , .

false . .

left side

200

53

245
283
57
58
72
75
90
90

289

.. 136

.. 80

.. 288

.. 189

I.

PAGE

Infarctus Laennecii . . . . 45

Inspection, value of in diagnosis. . 11

Insufficiency of aortic valves . . 120

mitral valves. . . . . . 131

tricuspid valves . . . . 135

Intermittency, diagnostic value of 40

Irregularity in pulse, cause of . . 37

■ rythm 39

Irritable heart . . . . . . 263

K.

Kidney and heart disease, combined 284

pathology of . . . , 286

symptoms of . , , . 294

■■ diagnosis of . . . . ' 314

prognosis of . . . . 316

from heart failure to

secondary renal disease. . . . 321

treatment of . . . . 331

Kidney disease result of heart dis-

ease

343

L.

Leucorrhcea from heart disease . . 50
Liver-pulsation, what, sign of , . 139
Longevity in cyanosis . . . . 362

Lungs, congestion of, in heart failure 45

atrophy of . . . . . . 129

pigment deposit in . v . . 129

Malformations of the heart . . 360
Mental manifestations of heart
failure . . . . . . . . 174

in combined heart and

kidney disease . . . . . . 308

Mitral disease. Valvulitis . . 127

stenosis . . , . . . 130

insufficiency . . . . . . 131

follows aortic insuffi-
ciency . . . . . . . . 124

disease. Effect of on right

heart
— Murmur where heard

Mode of examining the heart

inspection . .

palpation

percussion

auscultation . .

Murmurs, how caused

flitting

musical

ana;mic

136
119
11
11
13
15
18
21
26
26
26

INDEX.

381

PAGE

.. 144
.. 147

Myocarditis, acute. .

chronic

Menorrhagia from heart disease . . 50

N.

Necrosis, molecular {see Fatty De-
generation) .
Nerves of heart . . . . . . 7

■ blood-vessels . . . . . . 8

Nerves, inhibitory. . . , . . 9

Nervous diseases of heart. . . . 250

palpitation . . . . . . 256

Niemeyer's compensatory pericar-
dial effusion . . . . . . 247

0.

Obesitas cordis . . . . . . 185

Objective symptoms of heart
disease . . . . , . . . 34

Obstructive murmurs . . . . 22

Oppolzer's divisions of pericarditis 229

P.

Paracentesis thoracis
Palpitation, cause of

diagnostic value of . .

— — nervous

.. 241

.. 34

.. 36

.. 256

Palpation . . . . . , . . 11

Parasites in the heart . , . . 194

Percussion, use of in diagnosis . . 15

Pericarditis, acute . . . . . . 227

Oppolzer's divisions of. 229

signs of.. ,. .. 232

diseases simulated by . . 235

treatment of . . . . 237

Pericardial adhesion . . . . 242

effusion . . . . . . 245

Petrifaction of valves . . . . 107

Piorry's pain in myocarditis . . 150

Pneumopericardium , . . . 249

Polypi of heart . . . . . , 194

Pulse in valvular diseases. . . . 28

Pulsation, jugular . . - , . . . 141

Pulmonary valves, disease of . . 133

• stenosis . . . . . . 134

insufficiency . . . . . . 134

disease, secondary . . . . 129

congenital . . . . 373

Prognosis, elements of . . . . 364

R.

PAGE

Reduplication of heart sounds . . 374
Regurgitant murmurs, how pro-
duced . . . . . - . . 22
Rupture of heart, causes of . . 195
traumatic . . . . 197

s.

Second sound, how caused

accentuation of

value of . .

Semi-lunar valves, function of

cause of disease in

Stenosis, aortic

mitral. .

congenital

orifice
Strain, effect of, on valves

on arteries

Subjective symptoms of heart

failure
Sub-paralysis of the heart
Syphilitic disease of heart
Systolic murmurs . .

of pulmonary

20
21
129
3
121
115
131

373

118

270

44
270
192

22

T.

Tension arterial, cause of . .

bulk of urine, signs of .

increase of, in B right's

disease
Thoracic disease and heart disease
Thymus gland, source of fallacy in

percussion
Traube's views of arteriole spasm .
of compensatory hyper-

trophy

of effect of aortic regur-

29
303

290
62

17

288

71
124

Reil, moderator band of . .

gitation on musculi papillares . .
Transposition of aorta and pulmo-
nary artery . . . . . . 361

Treatment of heart disease, general 200

combined heart and

kidney disease . . . . . . 331

Tricuspid valve. King's views . . 5

Kiirschner's views of . . 366

serious nature of failure

of 137

disease . . . . . . 135

■■ secondary . . . . 136

congenital

u.

Urine, bulk of, test of arterial ten-
sion 303

382

INDEX.

. PAGE

Urine, bulk of, decrease of, in heart

failure .. 323

getting up at nights to pass . 304

variations in amount . . 293

V.

Valves, mechanism of
causes of disease in . .

5

118

Valveless veins, early congestion of 44

Vaso motor innervation . . . . 7

spasm . . , . . . 288

Venous congestion. . . . . . 45

dilatation, from tricuspid

failure . . . . . . . . 141

I system, aids to diagnosis de-
rived from . . . . . . 29

Ventricles, action of . . . . 5

PAGE

Ventricle, left, changes in, from
Bright's disease . . . . , . 289

right, changes in, from left-
side disease . . . . . . 136

from disease of respira-
tory organs . . . . . . 61

Vocal resonance, use of . . . . 32

w.

Wounds of heart . .

z.

97

Zusammenhang of heart and
kidney disease . . . . . . 288

PRINTED BY H. K. LEWIS, 136, GOWEK STREET.

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